The COVID-19 Pandemic continues to devastate families across the globe. Our screens were filled with images of loved ones standing outside windows – trying to hold on to the hope that they would be reunited with those in nursing home care. For many, this reconnection with loved ones never came to fruition. In fact, CDC data revealed that in early Fall 2020, almost a fourth of all COVID-19 related deaths in the United States were nursing home residents and staff.

For me, the statistic wasn’t just numbers. My mother, who suffered from a chronic illness that affected her physical and neurologic status was placed in a similar care facility to build strength prior to having surgery. I can remember when she called me begging to be released from her confinement. Worried, I ran to the nursing home and for a moment I was able to stand outside her window and witness the confusion and panic across her face. When I attempted to interact with the nursing home staff to find out what was going on, their answers were limited at best. At worst, they were unavailable due to the demand placed on the facility. I was angry and frustrated at their—and my—helplessness.

I often reflected on that memory during my work with the AHRQ ECHO National Nursing COVID-19 Action Network, where I was able to more fully understand how the people on the other side of that “staff only” door experienced the pandemic and its tragedies.

The Network is a partnership between AHRQ, the University of New Mexico’s ECHO Institute, and the Institute for Healthcare Improvement (IHI). It provides free training and mentorship to nursing homes across the country to increase the implementation of evidence-based infection prevention and safety practices to protect residents and staff. Through the network, nursing home staff were able to participate in a 16-week training program developed by the IHI. Training centers serve as a hub that supports a large number of nursing homes across the country and provided an opportunity to come together to collaborate, learn from each other, and build community during a time when many felt isolated and alone.

My role at Shift positioned me to work as an improvement adviser through the Project ECHO model of telementoring. Although I became involved in the 16-week curriculum during week five, I was grateful that my training center was flexible and willing to adapt the coursework so that I could lead the Quality Improvement (QI) aspect of this project with empathy. At a time when nursing home staff are tired, overwhelmed, overworked, and in emotional and mental turmoil, it is critical that QI methods create psychologically safe environments where participants feel able to share the gravity of the situation they have faced since the start of the pandemic. Understanding how a system is impacting people working or living within a system is critical to Shift’s improvement approach.

Project ECHO determined the curriculum prior to the course start, including 16 modules to cover the prescribed information, including lessons in QI. In an attempt to personalize the course and leave space for people to share their challenges and response to the program, I suggested that we both integrate QI into the coursework throughout rather than have a separate QI portion at the end of each module, and also merge two similar topics together. This way, the last call could be spent doing a “Project Echo Community Reflection and Celebration,” where we recapped the course and what we learned. To this day, “celebration” is still a hard word to say out loud. The pandemic has been hard for people, and the emotional trauma experienced in nursing homes is still heavy.

In the week before our final call, participants had five minutes of reflection where we collected responses in an online document. We asked participants to share how they were feeling during the pandemic. Responses like, “scared, apprehensive, exhausted, overwhelming sadness, and being in survival mode” filled the page. Some in my cohort saw a sliver of hope. Some pointed to feeling proud of the “perseverance of the staff,” “teamwork,” and “dedication.” Despite these positive attributes it was and continues to be a difficult time for nursing home workers. One person wrote:

“I saw my team really band together during the beginning of this. Families were understanding, staff were so strong.  Really went above and beyond. Now it seems like everyone is at each other's throats.  People are quitting. Families are yelling and we're trying to open up safely all at the same time. I feel like there should be light at the end of the tunnel, but it’s feeling a little dark.”

It was after reading these responses that it hit me in full force: For many frontline nursing home staff and many in nursing home leadership, it was as difficult to watch patients and colleagues fall ill and pass away as it was for those families looking on from outside the windows. On top of everything, the frontline workers—certified nursing aids, nurses, environmental and food service employees, and administrators—were under immense pressure and scrutiny from the nation to perform and protect our nation’s most vulnerable age group. It is a lot for anyone to bear.

This is why attempts to improve outcomes must be led with empathy. My colleagues and I at Shift are dedicated to elevating all perspectives – from the most vulnerable to the most powerful within a system. We believe that equitable change is created by centering the efforts for improvement on and co-creating with those who will be directly impacted by the improvement work. We need to understand how people within a system are experiencing that system in order to create equitable change. Unfortunately, because so many people on the frontlines are still operating in survival mode, while trying to keep patients and each other safe amidst relaxing safety measures, they were not able to participate in the project design. Having their perspectives would have only strengthened the outcomes that we are seeing.

This project also underscored that QI is not just a plug-and-play process. The improvement advisor or facilitator has to have the depth of improvement knowledge to be flexible and adjust the tools and skillset to the environment in which the participants live and work, taking into account everything from course curriculum to participants’ emotional states.

Despite these trying circumstances, Project ECHO is seeing significant positive outcomes. They recruited 99 training centers that provide customized training and mentorship to nearly 9,000 nursing homes across the country. If that feat was not impressive enough, the project has also moved into a second phase of this work, which emphasizes emotional support for staff. It also includes coaching with individual nursing homes in an attempt to partner with those on the frontlines. Shift is proud to play a critical role in this effort.