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Original Articles

Providing Quality Care to the Intellectually Disadvantaged Patient Population During the COVID-19 Pandemic

McGonigal, Michelle DNP, RN, NE-BC

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doi: 10.1097/CNQ.0000000000000331
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Abstract

CORONAVIRUS DISEASE 19 (COVID-19) has had an impact on many patient populations since its inception in December 2019 in Wuhan, China. On March 11, 2020, the World Health Organization declared the virus a worldwide pandemic and encouraged countries to take action to prevent viral spread.1 Recommended community infection prevention strategies included social distancing, elimination of large gatherings, hand hygiene maintenance, disinfecting frequently touched surfaces, and eventually quarantining segments of the population.2 Health care organizations were impacted because of the need for personal protective equipment (PPE) for staff, potential for an increase in ventilator requirements and critical care beds, and impending surge of infected patients. An additional concern was the potential for health care–associated infections due to the proximity of providers to patients and visitors. Isolating a patient and limiting visitation are strategies to deter COVID-19 spread within the hospital environment. While these restrictions are difficult for most patient populations, they present a unique challenge for those patients with an intellectual disability. This article focuses on strategies implemented to provide quality nursing care to adults with intellectual disabilities at a large urban teaching facility during the COVID-19 pandemic.

BACKGROUND INFORMATION

According to the American Psychiatric Association, people with intellectual disabilities have functional limitations in either adaptive or intellectual capabilities. Intellectual limitations would be primarily focusing on the person's ability to solve problems, make decisions, and understand concepts, whereas adaptive functioning would be focusing on the activities of living and effective communication skills.3 In a systematic review published in 2016 by McKenzie et al,4 the prevalence of persons with intellectual disabilities is estimated at 1% of the population. Organizations that focus on the care of persons with disability report rates of up to 3% of the population or approximately 6.5 million people in the United States.5 While there are many vulnerable populations within a community, patients with intellectual disability have been uniquely challenged during a pandemic due to the understanding of the concepts in regard to prevention of viral spread, the potential for comorbid conditions, and the status of the person's living or housing accommodations (familial, communal setting, or inpatient status). It is important to note the need for interdisciplinary collaboration throughout the continuum to provide quality and safe health care. This involves a few basic strategies such as treating the person as an individual, communicating to the patient as an adult, understanding past health care experiences, and listening to the carers, which could be community or familial caregivers.6

PREHOSPITAL CHALLENGES

The Centers for Disease Control and Prevention communicated recommendations related to stopping the spread of the coronavirus such as social distancing, hand hygiene, avoidance of touching the face, disinfection of frequently touched surfaces, and covering the nose and mouth when coughing or sneezing.7 These recommendations are challenging to achieve in the intellectually disadvantaged population due to the level of conceptual understanding, the impact of change to a person's normal living routine, and the need for caregiver assistance. In addition, the sanctions could have an emotional impact on the person including fear, separation, and loneliness. In an effort to assist care providers, recommendations were aimed toward the use of electronic methods of communication, limiting direct exposure and practicing diligent hand hygiene strategies. For adults living within the group or communal environment, remaining socially distant would be a difficult task to achieve. Currently, there are not statistics published on the number of COVID-19 cases transmitted in communal or group home settings, although there have been reported cases within nursing homes throughout the United States.

HOSPITAL CHALLENGES

Preventing the incidence and spread of the coronavirus was a top priority in health care institutions throughout the pandemic. Strategies were implemented in regard to protecting patients, providers, and the community in which the hospital served. As the COVID-19–positive cases presented to the urban teaching health care facility, it was important to evaluate each initiative and adjust nursing care as the patient's condition warranted. Quality and safe patient care was the top priority within the care continuum. The care of the intellectually disabled patient was particularly concerning and required critical evaluation of the recommendations and the impact to the care of the patient and the provider. It was important to note the unique needs of each individual in order to tailor nursing care to provide safe initiatives for all. Specifically, the health care team evaluated and implemented strategies in regard to communication, isolation, visitation, and the discharge process.

COMMUNICATION

Communication between caregivers and patients is imperative to achieving quality care within a health care setting. It is the obligation of the professional provider to inform and involve the patient in care decisions to the maximum extent possible. Providing health care information to an individual with intellectual disabilities can be a formidable task for the skilled provider depending on health literacy understanding and ability to share health needs and questions.8 For instance, the nurse may need to explain the requirement to wear PPE, keep monitor leads intact, or participate in respiratory treatments. In the intensive care unit, completing the patient assessment including shortness of breath, fever, or lung sounds becomes critical to evaluating illness progression. To be successful, it was important for the staff to evaluate the patient's communication preference and adjust strategies. Assessing the preference was achieved through direct conversation with the patient, family members, the communal care provider, or previous notation within the medical record. Important to note is the impact of nonverbal communication during the evaluation process. Having the knowledge of nonverbal mannerisms was especially effective in understanding the patient's health care needs. Nurses were astute in sharing information gathered during the patient encounter with other colleagues to enhance individual interactions between providers. The nursing staff was aware of the additional time requirement with completing care duties and provided clear and concise instructions to alleviate fear and anxiety as much as possible. The impact of successful communication strategies was pivotal to providing safe and quality nursing care and was a key concept in caring for the COVID-19 patients throughout the continuum.

ISOLATION TECHNIQUES AND THE USE OF PPE

Isolation of patients to prevent the spread of illness can be a challenging strategy for nurses and patients. The use of PPE including masks, gowns, gloves, and hair coverings can be frightening and could limit the interaction among the patient and the caregiver. The intent during the COVID-19 pandemic was to initiate restricted time spent in the patient's room by condensing nursing activities as much as possible. For example, registered nurses performed vital signs, respiratory treatments, assessments, and bathing versus the addition of ancillary health care member participation in the patient care activities. While prudent in nature to protect the caregiver, quarantining can induce emotional suffering in addition to physical illness. It was important to share educational information and the reason for isolation and use of PPE to assist in alleviating anxiety and fear. The communication to the patient was tailored according to the level of comprehension and was presented as clear and concise as possible. To limit patient impact to isolation implications, the nursing staff investigated opportunities to divert the patient's attention to positive options. A few of the alternatives included introducing favorite entertainment activities such as music, television, and computer games. Providing the COVID-19–positive patient with video visits with loved ones was particularly successful throughout the hospital stay. Importantly, the nurse needed to have an understanding of the patient's normal level of interaction and activity in order to prevent the negative consequence of isolation.

VISITATION

One of the strategies to prevent spread of infection during the COVID-19 pandemic within the urban teaching facility was the elimination of routine visitation to inpatients. Telephones and video visits were provided as a communication strategy to assist with progress updates between patients, families, and caregivers. In addition, physicians and nurses provided a daily update to a designated person to communicate the patient's illness progression. If the patient exhibited a need to have a family member or caregiver present, the person was supplied with PPE to protect him or her and the hospital staff. In regard to the intellectually disadvantaged patients, the nursing staff adjusted the recommendations as needed in order to alleviate emotional suffering.

DISCHARGE PROCESS

Discharging a COVID-19 patient was an important step in the hospitalization process that started on admission. The care manager shared post–acute instructions early in the stay so that appropriate arrangements, including cleaning procedures, could be completed before returning the patient to his or her home. In an effort to decrease the impact on the intellectually disadvantaged patient, the goal was to return the person to his or her normal living environment as soon as it was determined safe from a medical standpoint. In order for this to be successful, the communication between the hospital provider and the home caregiver needed to be frequent and complete, thus maintaining a partnership in the care of the patient.

RECOMMENDATIONS

The COVID-19 pandemic has impacted health care delivery in a short period of time. It has illuminated the need to be able to care for vulnerable populations without creating health care disparity. One recommendation would be to provide education to health care professionals on communication strategies for the intellectually disadvantaged patient population. The focus would be to display information in creative teaching formats that would assist comprehension and alleviate the fear and anxiety associated with care delivery initiatives. Another recommendation would be to formalize partnerships in care delivery between acute and post–acute providers. This would include information sharing on successful patient-specific communication strategies and techniques that would ultimately improve the ability to share health care initiatives.

CONCLUSION

The COVID-19 pandemic has highlighted opportunities for improvement within health care globally. Nursing care of the intellectually disadvantaged adult was noted to be an additional challenge during this time and has spotlighted the need for learning opportunities in regard to advanced communication techniques, patient teaching strategies, and a deeper understanding on the prevention of viral spread in vulnerable populations.

REFERENCES

1. World Health Organization. WHO timeline—COVID-19. https://www.who.int/news-room/detail/08-04-2020-who-timeline–covid-19. Accessed April 27, 2020.
2. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID 2019). https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. Published April 24, 2020. Accessed April 27, 2020.
3. American Psychiatric Association. What is intellectual disability? https://www.psychiatry.org/patients-families/intellectual-disability/what-is-intellectual-disability. Accessed April 27, 2020.
4. McKenzie K, Milton M, Smith G, et al. Systematic review of the prevalence and incidence of intellectual disabilities: current trends and issues. Curr Dev Disord Rep. 2016;3:104–115. doi:10.1007/s40474-016-0085-7.
5. Special Olympics. What is intellectual disability? https://www.specialolympics.org/about/intellectual-disabilities/what-is-intellectual-disability. Accessed April 27, 2020.
6. Mimmo L, Woolfenden S, Travaglia J, Harrison R. Partnerships for safe care: a meta‐narrative of the experience for the parent of a child with intellectual disability in hospital. Health Expect. 2019;22:1199–1212. doi:10.1111/hex.12968.
7. Centers for Disease Control and Prevention. How to protect yourself and others. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. Accessed April 28, 2020.
8. Seibert Primeau M, Talley B. Intellectual disabilities and health care communication: a continuing education program for providers. J Contin Educ Nurs. 2019;50(1):20–25.
Keywords:

communication; intellectually disadvantaged; pandemic

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