Continuing our series of interviews with doctors and other medical personnel in the era of Covid-19: A recently graduated occupational therapist in a nursing home told us what her life is like in the era of Covid-19.
Here, she tells us how she was pushed into working at a nursing home due to Covid-related hiring restrictions, but has since grown to enjoy it. She discusses the difficulties her patients are having in dealing with isolation, containment, and a cessation of many everyday activities, and tells us how the roles of occupational therapists have shifted during Covid.
The occupational therapist describes how changes within the nursing home have progressed throughout the pandemic. She also talks about what changes she thinks will be necessary to put into effect going forwards, and touches on the pandemic’s effects on her daily life and her own predictions for the future.
Here’s a transcript of our conversation, lightly edited for length and clarity.
Phoebe Pinder (CHC)
What has surprised you most about the Covid era? Both in the nursing home and outside of it as well?
I think initially I was most surprised by the way that political and health systems responded to even a threat of Covid. I don’t think they took large or fast enough measures to prepare for the possibility of a pandemic, despite there being clear warnings in China and European countries. So I remember feeling really anxious during the end of February, beginning of March, because it was very clear that the virus was coming, but there wasn’t widespread testing. It was just very clear that our leadership and our organizations were not equipped to handle this, and weren’t doing their best to respond to it. I think that surprised and angered me the most in the beginning of this era.
What also surprised me is the way that people have been behaving and responding to it. Even with simple things like walking in New York City, people give their two cents about your behavior and what you’re doing, both positive and negative.
One time, I was walking down the street wearing scrubs going to work. I wasn’t wearing a mask because at the time I was wearing tons of PPE throughout the day and it’s just exhausting constantly wearing that stuff. So in the morning, I would just walk without a mask for a bit because it’d be really early. There’d be no one on the streets, and I made sure to be walking on the street or at least six feet away from anyone I was around. But then someone basically yelled at me for not wearing a mask. People get really, really aggressive about that.
Within the nursing home…I think nursing homes sometimes get this bad rap, especially for patients not wanting to be there, preferring to be at home. I think that’s definitely the case now during the Covid era, with patients not getting visitors or having the ability to see their families.
There’s no more daily schedule, essentially. There’s usually recreational therapy and activities throughout the day. Now, all of that is shut down. So it’s surprising to see, the nursing home has essentially become more like a hospital. I’ve worked in acute care and it’s a short day, so most people are okay with there not being a lot of activities and being bed-bound, but now the patients are basically confined to their rooms because of the virus.
They’d be able to go outside in the past and be able to go to different floors, and attend groups, and all of that is just no longer possible. I can’t imagine what the patients are going through without having contact for an extended amount of time.
‘I feel like I’m in a prison’ and ‘I feel trapped’
How are the patients handling it?
I think things were a lot more strict last month. Now there’s Covid floors and non-Covid floors. The non-Covid floor patients are required to wear a mask when they’re in the hall, but not in their own rooms. There is a bit more socializing — they can come out of their rooms and they can talk to residents that they know. But a lot of them who can’t come out in the hall without, for example, an occupational therapist or physical therapist bringing them out, will just stay in their rooms all day.
They’ll say things like, “I feel like I’m in a prison,” “I feel trapped,” and it’s really sad. Of course, staff is doing their best to have them talk to family members, but I think it’s really hard on those patients who have dementia or have cognitive deficits. That Facetime or that video chat isn’t really doing anything for them. They’re not really aware of what’s going on; they need more physical tasks to do.
You have patients in the nursing home who have Covid?
When I first started, there were Covid patients throughout all the floors, and I was working with Covid patients. But now there’s an effort to get Covid out of nursing homes. I mean, they were doing this throughout, but it was just so widespread that it was hard to do.
Now, they’re testing patients at least weekly if not more. They move Covid-positive patients to specific floors that are only Covid. Only certain nursing staff and therapists will work on that floor, and won’t go to any of the other floors.
So now I’m no longer working with Covid patients. But it’s kind of scary because I went from wearing tons of PPE to now just wearing a mask, and there’s still obviously exposure. People get tested positive all the time and then have to move floors.
Regular testing of staff members
That’s scary. Are they testing the staff at all?
Yes. Now we’re required to be tested two times a week, regardless of whether we’ve had Covid before or we have antibodies. It started out that we’d have to go to CityMD or do outside testing, but now we’re able to get testing through the facility. I think most facilities are doing that now too.
Is it just a nasal swab test?
Just the nasal swab, yeah. And if we don’t get it, we’re not allowed to work. If we test positive, then we’re supposed to be quarantined for 14 days and can’t come to work.
Those are the new policies. It used to be that as long as you were symptom-free, you would be able to come to work because I guess there was such a shortage of staff that they needed everyone there. But now the goal kind of shifted towards “we want to get Covid out of here,” so if we test positive, we can’t come to work.
Are you guys getting antibody tests at all?
I got an antibody test. But even if you test positive for antibodies you still have to take the regular nasal swab tests because there’s such mixed research in terms of how long you have immunity for, and also all these tests are sort of — whether they’re effective and accurate is really so questionable. There’s no real regulation. I think their main goal is to see if you’re positive and if you are, you can’t come to work even if you’re asymptomatic.
Job-hunting in the era of Covid-19
What has most changed for you personally in the Covid era?
For me, personally, I was pursuing jobs in hospitals and inpatient rehab. Once Covid hit, the hiring process became very different, and those places weren’t hiring therapists. But there was a demand for nurses and OTs and PTs for nursing homes.
The way I started my career was affected by Covid in that I never saw myself working at a nursing home because it was just never something I was interested in, but I’ve really, really liked it so far. It’s also sort of dictated a lot of decisions that happened over the past month with my job, with moving into the city because I didn’t want to affect my parents and if I did have Covid, I wanted to mitigate the spread by not traveling so much.
And even in my day to day, I’m not sure if the whole “you’re asymptomatic but can still carry the virus” is true. To protect my patients, to protect the vulnerable, elderly, etc., I do my best to do things like going grocery shopping early in the morning on Friday or on off hours. So I think it affects my day to day and my decisions.
I guess it’s also affected me in the way that I’ve been working with my patients. I feel a lot more empathetic to their needs. Just understanding where they’re coming from and the lack of socialization and lack of ability to do whatever they want to do has made me more empathetic, more understanding.
More restrictions for patients
What do you think will be the long-lasting changes for nursing homes and assisted living facilities?
For the patients, I think that there are going to be a lot more restrictions.
For right now, the recreational therapy, which is a big part of their day in terms of group therapy, is no longer going on. That makes the day to day pretty hard for the patients.
There are short term and long term patients, but a lot of patients do get discharged, and if they had a bad experience, I feel like it may affect their perspective on going back to a nursing home or subacute rehab in the future.
How it works is a patient will be hospitalized for something like acute care, and then an occupational therapist in physical therapy will refer them to something like a subacute or nursing home because they can’t go home safely. But ultimately it’s up to the patient what they want to do, and in the future I could see patients not wanting to go back because they’ve had such a negative or isolating experience this time.
That could be detrimental because then they’ll go home and not have the proper support.
On the administrative side, they’re obviously going to have to put in place a lot more policies and procedures surrounding Covid and protective care, which they’ve already done, but I think that’ll just keep growing and keep changing.
Therapy restricted to patients’ rooms
If you’re not doing the recreational therapy, what do you do on a daily basis with the patients?
Right now, because of Covid, a lot of the therapy is restricted to patients’ rooms. It used to be that there’d be a gym and we could do the therapy there, but now most of it is restricted to the patient’s floor and their room.
What we do depends on the functional level of the patient. For some of them, even just getting to the edge of the bed is super difficult and tiresome, so we’d work on something super simple like that.
We cover things like dressing, brushing their teeth, washing their face. For those higher level patients, we’ll do exercises for balance or strengthening. A lot of them need help with walking, so that’ll be part of the session too.
Occupational therapy also covers cognitive deficits or impairment, so sometimes I’ll work on cognition with the patient, and things like managing finances and writing checks.
It’s different from a nursing role where nurses will do everything for the patient. For OTs and PTs, we work on having the patient facilitate their own independence, so that they can do a lot of things themselves. It’s really holistic, it just depends on whatever the patient needs, that’s what you focus on.
During Covid are patients allowed to socialize with each other at all or is everyone pretty much totally isolated?
What I’ve noticed at least in the past few weeks is that, because they’re attempting to get Covid out of the nursing home and there’s specific Covid wards, they are now allowing patients to socialize.
We can’t really restrict that anyway — the patients have the right to do whatever they want to do. We do stop patients from going into other people’s rooms for privacy reasons, unless it’s mutual that they both want that, but I’ve seen a lot of patients in the hall socializing.
We’ll just remind them to wear their mask and keep their distance, but we can’t force them to do that — if they want to be close then that’s their decision. We just try to educate them and make sure that they’re informed. That’s pretty much all we can do.
What were things like at the beginning of Covid, versus the peak versus now?
I wasn’t at the nursing home the month that it first started. But I know that at least OTs were taking on different roles.
There was a shortage of nurses, with people leaving, quitting their jobs, or just getting sick. I think it was a more team approach, like all hands on deck. OTs were helping nursing with dependent patients who couldn’t bathe or feed themselves, and taking on those roles.
From the therapy perspective, it changed a lot. It was more like making sure that the patients were safe and comfortable, rather than providing therapy. It was just, I guess, how you would respond to a time of crisis — roles overlap, and everyone’s just working together to provide the best care.
Now I think there’s a lot more organization. Our state government and administrators have put a lot more policies in place, and everything seems to be a bit more organized.
People kind of know how to respond to different situations and are just more well-equipped. As it progressed in the past few weeks, I can see that we’re starting to shift back into our roles as nurses and OTs and there’s less of an overlap now. And as I said, we’re now being tested.
The goal is to make nursing homes Covid-free. That’s definitely changed over the past two weeks. Before that, I can’t say this for sure, but I heard that staff could test positive for Covid, but as long as they were asymptomatic, they could still go to work, because there was just such a shortage of staff. That now is not the case, so that’s definitely changed too.
Going forward, how do you see nursing homes balancing care and also protecting against future pandemics?
I think it’s hard. I think we’ll just need a lot more research and data on this. I think the science will dictate how we move forward.
Whether there’ll be a vaccine or whether there’ll just be better treatment, it’s hard to say how to move forward without knowing more about the virus. Two weeks ago, when we first started doing the twice a week testing, if you tested positive for antibodies, that would exempt you from the twice a week Covid testing. And within a week, they change that policy.
So I think that as we move forward, things are just going to keep changing. The more information we have, the more we know about the virus and about the tests that we’re using, that will allow us to make more informed decisions in terms of what type of care we provide, and what types of measures we’re taking.
Preventing another spike, and finding funding
Is there anything that you think is going to be particularly challenging?
People definitely want to start going back to work and going back outside. But if we can avoid spreading the virus on a larger scale, then we can keep it out of nursing homes, we can keep the vulnerable populations safe. That is priority. So one of the challenges would be to prevent another spike or outbreak, because if that happens, we’ll just keep putting our health care system under more and more strain, and I don’t know how long that could feasibly work.
There’s also the question of how much funding we have. All of the things that are going on now will definitely affect health care in the future. Even just thinking about little things like insurance covering all these tests, and how much money it’s costing them.
Twice a week testing for all nursing home staff across New York, that’s costing millions of dollars. It’s going to affect budgets for next year and the years to come. I can definitely see cuts happening in not only healthcare, but in all different businesses.
So moving forward, I feel like there’ll definitely be challenges in preventing another spike, and in figuring out funding and budgets. I think testing is also another challenge.
When I went to get my Covid test, they told me that it’s only like 70% accurate and I definitely did not know that. I thought that was shocking because then there’s a 30% chance that it’s not right. We need better testing. Moving forward, we need faster and more reliable test results, otherwise we won’t be making informed decisions.
Physical and mental well-being
Is there anything you would like people to know, as an occupational therapist during Covid?
Yeah. I think, at least in the nursing home and most hospitals, every health care team member has a different role. The doctors will be making sure that patients are on the right medication and they’re being treated on the medical side, and the nurses will make sure the patients are safe and that they’re implementing all the things that the doctors have put in place.
But for occupational therapy and physical therapy, the main goal is getting the patients moving and getting them out of bed. I think that really affects their day to day and their mental well being.
So I think therapists — OTs and PTs and speech therapists — have a really important job now during the Covid period, especially now that there’s no recreational therapy in nursing homes. We’re the ones going in, getting patients out of bed and getting them motivated. Otherwise, they’d just be bed-bound and continue to decline.
OTs and PTs can really make the patient feel better by helping them do things independently — not only assisting them to do whatever they need to do, but facilitating their own autonomy. Just the other day, there was someone who would otherwise be in their room all day, but I did their therapy outside and then they were able to talk to someone else that was out there.
So I think that, especially during the Covid era, therapists are filling in more than just therapy, they’re helping with the patient’s physical well being and their mental well being.