COV-19-DILEMMA: Between Protection Benefit and Social Harm. Impact of Non-Pharmaceutical Protective Measures in Nursing Homes

At the onset of the COVID-19 pandemic, health authorities and the medical community focused on hospitals and intensive care units because of the severe course of infection in a significant proportion of patients. At the same time, a tragedy of an even greater magnitude unfolded elsewhere: The over proportional number of deaths of older people. Non-pharmaceutical interventions (NPIs) such as physical distancing, movement restrictions or social isolation were applied to protect the lives of the residents, who were quickly identified as most vulnerable to health deterioration. While NPIs can be powerful tools for pandemic controls, they can also have harmful direct and indirect effects. The proposed study will investigate this dilemma of harms and benefits of NPIs in nursing homes during the current COVID-19 pandemic. The overall objective of this study is to gain a comprehensive understanding of NPIs, e.g. social isolation practices and their impacts on residents and their families. Of particular interest are the underlying mechanisms and the consequences of NPIs to best inform future public health policy, and nursing home responsibles in addressing the threats of the pandemic for vulnerable populations. Nursing home responsibles are in a (ethical) dilemma and may benefit from policies to support their decision-making on the stringency of isolation measures, facing their positive and negative impact. An exploratory mixed-methods research design will be applied to tackle this aim:1) A full census online survey will be distributed among all nursing homes in Switzerland. Nursing home responsibles will be asked about the facility size, the region (urban vs. rural), state or private responsibility, as well as epidemiological information regarding COVID-19 outbreaks, duration, manner, and specific forms of conducted NPIs. The survey questions will be informed by pandemic response recommendations suggested in the literature. Furthermore, we will collect pandemic preparedness of the nursing homes using an adapted version of the COVID-19 preparedness survey. The information about the conducted NPIs will be used to calculate an index indicating the strictness of conducted NPIs. 2) Based on the NPI index (ranging from loose to very strict NPIs) and different national regions selected nursing homes will be invited to participate in the second study part (purposive sampling). Within this study part we will explore perceptions, experiences and consequences of the implemented NPIs in focus groups with the nursing staff, responsibles and primary care physicians (PCPs). The overall aim of the focus groups is to gain an in-depth understanding of the conducted NPIs, the reasons for the decisions reached, the harms and benefits caused by the measures, concrete suggestions for improvement and potential lessons learned. In addition step 2) will include, a mixed methods study among the residents and their next of kin will be conducted in this study part. For the mixed methods study, qualitative partially structured interviews among residents and their next of kin will be conducted. The topics will be comparable to the ones in the focus groups. Residents and their next of kin will be recruited either dyadic (residents and their next of kin simultaneously) or monadic (residents or next of kin). In addition to this 'classic' qualitative data collection a pen-and paper survey containing the Impact of Event Scale-Revised will be conducted. The scale is a widely used tool to assess posttraumatic stress disorder. In contrast to usual procedures in standardized surveys, the data collection will be audio-recorded and field notes will be taken to gather additional qualitative data, including comments and field notes of the interviewees. We expect to gather in-depth understandings of local practice patterns of pandemic preparedness and undertaken NPIs in nursing homes and their effects on residents, their next of kin as well as on staff including responsibles and nurses in the context of the COVID-19 pandemic. Overall, the COV-19-DILEMMA study will provide evidence describing and explaining the effects of different NPI measures implemented in nursing homes on quality of life and other psychological and sociological measures of residents and their next of kin. The evidence will be informed by different data sources collected in an interdisciplinary way that can hardly be obtained by classical single methods approaches.