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CLINICAL FEATURE

COVID-19 and Inpatient Rehabilitation Nursing Care: Lessons Learned and Implications for the Future

Camicia, Michelle E. PhD, RN, CRRN, CCM, NEA-BC, FAHA, FARN, FAAN1; Cournan, Michele C. DNP, RN, ANP-bC, FNP, CRRN2; Rye, Jill DNP, RN, CRRN, CNL, FARN3

Author Information
doi: 10.1097/RNJ.0000000000000337
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  • CME Test

Abstract

Introduction

The global novel SARS-CoV-2 coronavirus (COVID-19) pandemic and the associated care needed for those with disability following illness have significantly impacted nursing practice in the inpatient rehabilitation facility (IRF) setting throughout the rehabilitation process, from the preadmission assessment to care delivery and preparation for discharge. Although the science of the sequelae of the virus continues to evolve, currently there is no standard of care in rehabilitation settings, and there is a limited evidence base to organize and provide care. We share insights learned from the COVID-19 response at three IRFs of different sizes and regions across the nation. The purpose of this article is to

  1. discuss the impact of COVID-19 on addressing the needs of rehabilitation patients with and without COVID-19 and their families throughout the rehabilitation trajectory;
  2. describe regulatory changes, adaptation to program structures and processes, and strategies to address patient, family, nursing staff, and resource needs; and
  3. provide strategies and recommendations for managing post-acute care in the IRF setting during the COVID-19 pandemic.

Background

The impact of the COVID-19 pandemic on IRFs across the United States is still evolving. Although there is limited published research in this area, professional associations (e.g., Association of Rehabilitation Nurses [ARN], American Medical Rehabilitation Providers Association, and American Physical Therapy Association) have noted that many IRFs have experienced disruption and have had to adapt facility structures and programs accordingly (American Medical Rehabilitation Providers Association, 2021; American Physical Therapy Association, 2021; ARN, 2021). Some IRFs that are a part of a hospital system had staff and beds repurposed to serve the acute care population, when the acute care hospital exceeded their surge capacity. This reallocation of beds and staff impedes access in the region for those who need an IRF level of care after a disabling injury or illness (Wade, 2020). Other IRFs expanded the population they served to include patients with COVID-19, some with dedicated COVID-19 units and negative pressure rooms (Eddy, 2020). Most IRFs across the country have admitted “COVID-19 recovery patients” (tested positive for COVID-19 but are no longer infectious) who are diagnosed with debility as a result of severe symptoms—many following a prolonged hospitalization. This was made possible by a waiver of the “60% rule” by the Centers for Medicare & Medicaid Services (CMS, 2020a). Regardless of the program structure, the stress on rehabilitation nurses has been pronounced. These stressors are a result of fears of transmission, concerns about the effectiveness and availability of personal protective equipment (PPE), increased family responsibilities because of school/childcare closures and/or a reduction in employment/income of family members, availability of the vaccine, and ambiguity about the safety and efficacy of the vaccine.

Patients and families are also under tremendous stress. Not only do they share many of the stressors noted above, but they also have to deal with the impact of a new disabling condition. This is amplified by limited support from family and friends because of COVID-19 visitation restrictions. Family caregiver training and preparation were also compromised as a result of restricted visitation, despite the use of technology and other solutions to address these needs.

Our knowledge of COVID-19 has rapidly evolved as scientists focus their efforts on understanding how the virus and its variants are transmitted and how they behave, acute treatment modalities, and management of long-term outcomes of those infected by the virus. The guidelines published by the Centers for Disease Control and Prevention (CDC, 2021a) and associated recommendations continue to evolve as the science advances. Organizations and health professionals must adapt accordingly, modifying policies, procedures, and staff and community education. Rehabilitation nurses must also be familiar with and share resources for people with disabilities, patients, families, and staff (see Table 1).

Table 1 - Rehabilitation Nursing COVID-19 Resources
Centers for Disease Control and Prevention
https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
• Up-to-date resources for healthcare providers
• Topics include:
○ Caring for patients
○ Preventing and controlling COVID-19
○ COVID-19 vaccine clinical resources
○ Nonhospital settings
○ Facility operations
○ Guidance and resources
○ Support phone lines
Association of Rehabilitation Nurses
https://rehabnurse.org/advance-your-practice/collaborative-resources/covid-19-resources-for-rehabilitation-professionals
• General resources by public health organizations
• Telehealth and virtual medical services
• Medicare and Medicaid updates
• Guidance for standards of care and clinical strategies
• Policy and advocacy
• Peer-reviewed COVID-19 resources for nurses
• Mental health resources
• Discounts and freebies for nurses or healthcare workers in general
• Resources to provide patients
American Nurses Association COVID-19 Resource Center
https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/
• Vaccine information and resources
• Video education series links
• Coronavirus Response Fund for Nurses
• FAQs
American Nurses Association Well-Being Initiative
https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/what-you-need-to-know/the-well-being-initiative/
• Well-being tools and resources such as a journaling program, sleep resources
• Stress self-assessment
• After work checklist
• Free and discounted therapy for nurses
• Suicide prevention and resilience resources
• Financial support
American Association on Health and Disability
https://aahd.us/covid-19/
• Video series on COVID-19 and disability
• Disability resources on COVID-19
• COVID-19 and state policies, including Medicaid
• Advocacy resources
• Governmental resources
American Medical Rehabilitation Providers Association COVID-19 Resource Center
https://amrpa.org/Advocacy-News/COVID-19-Resource-Center
• CMS waivers and other provider relief
• Information call series recordings
• Medicare payment resources
• Healthcare provider resources
• Prevention resources
• Reporting resources

Inpatient Rehabilitation Care During the COVID-19 Pandemic

The pandemic has posed novel challenges for rehabilitation nurses. Facilities were required to evaluate and redefine their structures and modify the rehabilitation process (preadmission through discharge planning). In addition to caring for the traditional rehabilitation population (e.g., patients with stroke, brain injury, and spinal cord injury), rehabilitation nurses and other health professionals also delivering clinical care to patients recovering from COVID-19 support and prepare family caregivers for the discharge home using novel strategies. Health professionals continue to provide support to the patient and their family amidst the uncertainty of the trajectory of the illness and associated recovery.

Facility Program Structure

Facilities have and continue to modify their structures in various ways in response to the pandemic. Factors that affect program structure include the unit/facility size, geographic location, COVID-19 community prevalence, state regulations, and demographics of the population served. Some IRFs care for patients actively infected with COVID-19 in designated units such as at a large freestanding rehabilitation hospital in Schenectady, New York. Most IRFs are caring for patients recovering from COVID-19 but who are no longer infectious. The structures are dynamic and evolve with the science. For example, a facility may have a designated COVID-19 recovery unit and then transition to comingling these patients with the general IRF population as new knowledge about the window of viral load necessary to transmit the virus is discovered.

Deciding to accept patients with a positive COVID-19 test result takes a great deal of planning. Facility leaders need to consider if they have the necessary resources to care for these patients. Questions to consider include: Is the needed PPE available? Are staff adequately trained in PPE donning/doffing, and are they willing to work with this population? Does the facility have sufficient and accessible storage for all of the required PPE? Can the facility provide dedicated staff to the “COVID-19 unit”? Is it possible to create a separate unit and gym space for patients who are COVID-19 negative? How will patients who are “newly negative” or who have positive antibodies be transitioned to the “main unit”? How will aerosolizing procedures be managed? How will discharges be facilitated? Will admissions have to be “scheduled” to avoid comingling positive and negative patients in the same area?

Regardless of whether a facility accepts patients who are positive or not, all facilities must have procedures for “patients under investigation,” those patients presenting with COVID-19 symptoms or present with other reasons for concern. In addition, procedures for staff, visitors (when allowed), and patients who become positive must be developed for the associated contact tracing, notification, and management of these events. The CDC maintains current recommendations for managing these issues on their website (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html; CDC, 2021a). These recommendations are generally accepted by facilities and must be followed consistently. The CDC recommendations require regular monitoring for updates and leadership oversight.

Regulatory Changes Related to COVID-19

There is no doubt that COVID-19 has had a significant impact on IRF programs. When the pandemic was declared a public health emergency (PHE), several waivers and other processes were put into place to facilitate patient care (CMS, 2020a). Many managed Medicare plans suspended the need for preauthorization prior to admission to rehabilitation as CMS encouraged this expanded flexibility during the PHE. This eliminated some of the administrative burden and led to faster admission decisions and associated transitions. However, the requirement for preauthorization is not mandated by CMS, and many plans have resumed the preauthorization requirement.

CMS suspended several prior regulatory requirements to decrease the administrative burden on IRFs. Early in the pandemic, CMS notified facilities that all audits for IRF stays of admitted patients were suspended during the PHE (CMS, 2020a). However, these audits resumed at the end of June 2020. In addition, CMS suspended the 60% rule and the 3-hour rule and lifted the requirements to report quality data. The 60% rule remains suspended for the length of the PHE; however, to activate this rule, facilities must indicate the desire to remove cases from the 60% rule calculation by placing a specific code on the universal bill. The 3-hour rule is also suspended for the duration of the PHE, but IRFs should advocate for reinstating this as soon as possible to facilitate differentiating the IRF from an subacute level of care. Although the 3-hour rule was suspended, some facilities perform therapy 15 hours over 7 days, as not all COVID-19 patients are able to tolerate 3 hours in 1 day. The suspension of submission of quality data applied to the fourth quarter of 2019 and to the first and second quarters of 2020 (CMS, 2020b). This suspension ended on June 30, 2020. Beginning with the third quarter of 2020, IRFs had to report data to the National Healthcare Safety Network and on the IRF-PAI. These rulings are dynamic, and it is essential that IRF administrators stay abreast of these regulatory and reimbursement changes.

Additional assistance to IRFs and providers is available through other waiver programs. Some states facilitated the ability for providers to practice across state lines without the need to license in that state. The CMS expanded the rules and billing for telehealth/telemedicine services. This enables the provision of care to those in most need while minimizing the risk of exposure and the use of PPE. The Joint Commission and the Commission on Accreditation of Rehabilitation Facilities, in addition to many state departments of health, suspended regulatory and licensing surveys for a period of time, though these surveys have resumed with limited in-person or virtual surveys.

Preadmission Considerations

The preadmissions process is impacted by a change in the mode of evaluation. Most rehabilitation hospitals perform on-site evaluations where they meet the patient (and often family) for assessment input and orient the family unit (the patient and their family) to the rehabilitation process. In other facilities, where there is a uniform electronic health record in an integrated care delivery system, the preadmission assessment is performed through record review and remote communication with clinicians and family; thus, no change in process has resulted. The role of the preadmissions rehabilitation nurse liaison is impacted in most facilities where liaisons moved from face-to-face to phone intake or chart review after hospitals eliminated entrance by any nonemployee. This change impacted the screening process and, in some cases, led to different decisions than would be made if the patient was assessed face-to-face as nuanced information may not be gathered with a remote assessment.

The policy on COVID-19 testing preadmission must be established by the IRF and implemented by the preadmissions nurse liaison. IRFs must determine when and if to test at preadmission. This may vary by the setting(s) where the patient resided in the past 14 days (e.g., skilled nursing facility or other aggregate living setting) and any prior testing (e.g., upon admission to acute care or preoperatively). If deciding to test preadmission, the mechanism and timeliness of test results impacts the process. The optimal situation is to have an adequate supply of “rapid-result” COVID-19 tests that provide results within 2 hours.

Admission of patients recovering from COVID-19 to an IRF that does not admit actively infected COVID-19 patients requires establishing a timeline for when to admit to the IRF. The current science (CDC, 2020a, 2020b) indicates unlikely transmission (replication-competent virus has not been recovered), thus ready for IRF admission, at 10 days after symptom onset for patients with mild to moderate COVID-19 and between 10 and 20 days after symptom onset for those with severe COVID-19 (Arons et al., 2020; Bullard et al., 2020; Korea Disease Control and Prevention Agency, 2020; Lu et al., 2020; Wölfel et al., 2020). For the latter, this conservative approach is adopted because patients are more likely to continue to be able to transmit the virus during this time period. For IRFs that admit COVID-19 patients, they must capture not only the date of the positive test but also the date of the onset of symptoms and the date the patient became symptom-free without medication. This information helps the facility to determine when the patient can safely be removed from precautions.

Rehabilitation Nursing and Patient Care During an IRF Stay

Patients recovering from a COVID-19 infection pose unique challenges for rehabilitation teams because of the lack of evidence of how patients recover from the virus. An understanding of the impact of COVID-19 infections on body systems may help multidisciplinary teams effectively develop treatment plans to promote functional recovery. Early infection complications cause damage to the lungs, heart, and kidneys. Many patients experience neurological symptoms such as seizures, headaches, confusion, vision loss, and encephalopathy. The most common comorbid conditions of the patient diagnosed with COVID-19 include hypertension, coronary artery disease, stroke, and diabetes (Sheehy, 2020).

Many patients hospitalized with COVID-19 require intensive care because of severe respiratory decline and the need for mechanical ventilation. This is commonly due to acute respiratory distress syndrome. Patients experiencing acute respiratory distress syndrome develop severe shortness of breath, while fluid builds in the lungs and reduces oxygen levels. Patients require aggressive respiratory management to ensure oxygen levels are maintained and to minimize further lung damage. As the patient recovers and moves to post-acute care, they need close monitoring of oxygen needs and respiratory effort. They may fatigue easily and require frequent rest breaks. Interventions such as incentive spirometry should be emphasized, and patients should be instructed on strategies such as diaphragmatic and pursed lip breathing (Incentive Spirometry, 2020). Oxygen saturation levels should be maintained above 95%, and patients should be closely monitored for shortness of breath to assess activity tolerance (Sheehy, 2020). The rehabilitation nurse should provide education on paced breathing and relaxation techniques to optimize respiratory function.

COVID-19 patients often experience cardiac injury. The exact mechanism of injury to the cardiac system may include viral injury, hypoxia, hypotension, drug toxicity, or acute inflammatory response (Barker-Davies et al., 2020). Patients should be monitored closely for arrhythmia, reduced ejection fraction, elevation in troponin I, cardiac insufficiency, and myocarditis. As the patient recovers, they often experience tachycardia, which usually resolves over time (Sheehy, 2020). Ongoing cardiac monitoring in the rehabilitation phase of recovery is important to avoid further complications.

Neurological complications are common during the acute stages of COVID-19 and often have residual effects. Critical illness polyneuropathy, a syndrome characterized by a complex sensorimotor neuropathy that leads to degeneration of axons in the nervous system, may occur. Patients experience generalized weakness (distal muscles are more affected than proximal muscle groups), distal sensory loss, muscle atrophy, and absent or decreased deep tendon reflexes. Ischemic stroke, polyneuropathies, headaches, confusion, seizures, and loss of taste and smell are common complications for these patients (Sheehy, 2020). Each member of the rehabilitation team must closely monitor patients for any neurological changes.

The long-term impact of COVID-19 on the musculoskeletal system is unknown. However, rehabilitation teams are very adept at managing patients with a loss of muscle mass and weakness. Patients with COVID-19 who require mechanical ventilation for prolonged periods and those treated with large doses of steroids experience osteonecrosis. Other complications of COVID-19 may include severe muscle pain and heterotopic ossification (Barker-Davies et al., 2020), tracheal stenosis, muscle contractures, pressure injuries, tooth loss, and hearing loss (Sheehy, 2020). Patients with underlying pulmonary disease have the most difficulty in regaining strength and endurance.

Facilities that have a large volume of patients with COVID-19 provide therapies in “COVID” gyms, whereas others perform all therapy in their rooms. All IRFs must attend to safety in shared treatment areas, ensuring the safety of other patients, staff, and visitors (where permitted). Strict distancing must be enforced between individuals, as well as wearing of masks that cover the nose and mouth.

Some IRFs who care for COVID-19 patients report an increase in the number of falls. We noted that, in our three facilities, this was due to the lack of line-of-sight into the patient’s room as doors are closed for isolation. Furthermore, the time required for staff to don PPE delays the response to the patient’s bedside. Family/visitors are also not present to address patient’s needs and share safety concerns. It is essential that rehabilitation nurses provide authentic hourly rounding to prevent falls with this population.

Patients who experience severe symptoms and survive after a prolonged hospital stay experience anxiety, depression, confusion, and posttraumatic stress disorder (University of Michigan, Department of Psychiatry, n.d.). Patients can experience isolation related to prolonged hospital stays amidst visitation restrictions. Furthermore, the patient may be burdened by the stigma associated with having COVID-19. This population requires constant monitoring for emotional distress and difficulty participating in their recovery. Psychological interventions focus on behavioral therapy and improving cognition.

Limited visitation has resulted in a lack of support for the patient and may exacerbate feelings of social isolation. Patients must be provided with psychosocial support amidst restricted visitation (Arenivas et al., 2020). Visitation can occur through a window or in an outside area maintaining a distance of at least 6 feet and the use of masks. The Americans with Disabilities Act and Section 504 of the Rehabilitation Act requires accommodation and exception for visitation of individuals with an intellectual or physical disability (U.S. Department of Health and Human Services, Office for Civil Rights in Action, 2020) early in the pandemic and was suspended in many facilities during the pandemic. Recently, facilities are increasingly allowing the patient one visitor.

Multidisciplinary teams must work together to set realistic functional goals while addressing the patient’s psychological and physical recovery. Patients recovering from COVID-19 often have complex impairments that require a holistic approach to recovery (Barker-Davies et al., 2020). Just like COVID-19 itself, it is challenging to predict the patients who will make progress toward goals and those who will not. Rehabilitation nurses must encourage, support, and provide hope during this uncertain recovery process.

Family Caregiver Engagement in Discharge Planning During Visitation Restrictions

To protect patients and staff, visitation in hospitals is restricted in many states. There are a variety of models from no visitation to limited visitation, and these rules may change based on COVID-19 prevalence in the local community. Patients who are COVID-19 positive are not allowed visitors. For all other patients, in most IRFs where visitation is restricted, the designated family caregiver is the only visitor who is allowed for the purpose of training in preparation for discharge. This is usually limited to a healthy adult family member or friend (18 years or older) who can visit for a specified time prior to discharge. Some IRFs allow the primary caregiver to come for the duration of the stay, though do not allow in-and-out privileges in order to minimize the risk of extending exposure in the community to persons in the facility upon their return. All visitors are required to wear a mask that covers the nose and mouth to reduce the risk of transmission in case that they are infected with COVID-19 (Brooks et al., 2020). Furthermore, temperature checks and symptom screening should be conducted with visitors prior to entry into the IRF, as well as daily rescreening for those who stay multiple days in the facility. In addition, frequent hand hygiene should be encouraged, in addition to maintaining physical distance from others.

Family caregivers of patients recovering from COVID-19 have the greatest challenge because, initially, in most settings, they were not allowed to visit. All training was completed remotely or through a glass barrier. Negative feelings were likely magnified as they were not able to support their family member in person through the rehabilitation journey nor receive the in-person support during training for the caregiver role. Family caregivers of all patients may have fears of acquiring COVID-19 while in the facility.

The Rehabilitation Nurse Case Manager is often responsible for screening caregivers for COVID-19 risk prior to visitation. Those at increased risk of acquiring infection because of close contact include persons who work or live in congregate settings (e.g., skilled nursing facility, homeless shelters, assisted living facilities, college or university dormitories; CDC, 2021a). Those who live in or have recently been to areas with sustained transmission and those living in crowded dwellings may also be at higher risk of infection. Geographic-specific risk factors must be considered (e.g., populations with high community prevalence, such as certain age groups or those that participate in high-risk activities). The case manager, in conjunction with the nurse leader, must weigh the risks of visitation by the designated family caregiver against the benefits when the only available caregiver is determined to be high risk.

Limited visitation affects the entire family unit and may compound the caregiver’s prepandemic feelings of isolation (Lutz & Camicia, 2016). The family unit’s ability to adapt to the disability may be impacted as the larger family and support system is not able to participate fully in the rehabilitation program. The isolation family caregivers experience may be magnified by quarantine, fear of bringing the disease home to other members in the household, or contracting the disease and being unable to provide care (Dang et al., 2020). Assuming the caregiver role amidst the pandemic may increase stress on family members and likely places them at even higher risk for the negative effects of caregiving. It is essential to help family caregivers identify a “bubble” of people who will be able to help them upon return to the home. It is even more important that family caregivers are assessed for their preparedness for the caregiver role during the pandemic (Camicia et al., 2021).

The pandemic is having a large financial impact on many families who are experiencing a loss of income. Added financial protections are available for families amidst the COVID-19 pandemic through the U.S. Department of Labor Families First Coronavirus Response Act (FFCRA). This act provided small- and mid-sized employers (<500 employees) with tax credits to provide paid leave for employees for COVID-related reasons. This leave could be used for family caregivers who need to provide additional care and support for their care recipient, in addition to benefits afforded by the Family Medical Leave Act and state-administered paid family leave, where available. These temporary protections of the FFCRA “sunseted” March 31, 2021 (U.S. Department of Labor, 2020). Rehabilitation nurses must be aware of and educate families of the availability of these resources.

Technology Solutions

Technology solutions may be utilized amidst the COVID-19 pandemic to decrease patient and family isolation, improve caregiver training and preparation for discharge, provide ongoing rehabilitation postdischarge, and maintain staff safety. The rehabilitation nurse educator is essential in the introduction and implementation of technology solutions to improve care delivery. The educator provides in-service education and designs programs to increase competence in the use of technology (ARN, 2015).

Patients can decrease isolation by regularly visiting with family and friends using a tablet or smart phone. They can stay connected through social media, though the patient must be assessed for the ability to psychologically manage these encounters. “Remote groups” can be offered within the facility or in online forums to provide peer support to decrease isolation.

Technology solutions are essential to overcome the challenges when planning for discharge during a period of restricted visitation. This includes conducting caregiver training virtually where the rehabilitation professional demonstrates techniques with the family caregiver observing remotely. Some facilities have a designated space with a window for in-person observation. For facilities where limited visitation is permitted, abbreviated training is enhanced through the provision of video recordings of the skills that will be required of the family caregiver. These approaches do not provide the hands-on skill building that is traditionally offered and may impact the preparation of family caregivers and increase readmission rates. Family conferences can be held through teleconference or Zoom.

A recent study found that family caregivers are interested in learning about other digital health tools to help them provide care, and many caregivers have already used at least one telehealth or mobile health caregiver management or support tool (Wicklund, 2020). Digital health platforms are available to prepare family caregivers who are not at the facility. For example, clinicians can send the family caregiver digital education, community resources, tasks to complete (e.g., home assessment), and surveys (e.g., caregiver assessment) directly to the caregiver’s (or multiple members of the family) mobile device. Many outpatient therapies are offered virtually during the pandemic. The inpatient rehabilitation team must prepare the patient and the family caregiver for this method of service delivery. It is essential that the IRF team ensure the patient and the family caregiver have the appropriate devices and access to engage in virtual rehabilitation visits. Technology can be utilized to support staff by limiting their exposure to patients contagious with COVID-19. For example, neuropsychology and recreation therapy can be provided via televisits to decrease the numbers of staff potentially exposed to the patient with COVID-19. Furthermore, team conferences can be held virtually to allow for physical distancing to decrease staff–staff exposure.

Leadership

The rehabilitation nurse administrator and nurse manager are critical in leading nursing staff and other members of the rehabilitation team through the challenges of the COVID-19 pandemic. They must stay abreast of the ever-changing guidelines and policies, communicate with staff transparently, ensure the provision of staff education, and provide strategies for managing staff anxiety and emotional distress. Early in the pandemic, some facilities had the luxury of being able to prepare their staff for the need to admit patients with COVID-19, whereas others, like those in New York and New Jersey, had significantly less time, as they were the first epicenters. Facilities that had little preparation time focused on staff safety, PPE donning/doffing reeducation, and the cleaning of equipment. Collaboration with peers across the country is essential to learn from others’ experiences.

Nurse leaders must stay abreast of new guidelines and updates to existing guidelines, revise policies and procedures, and provide education accordingly to ensure staff are supported to provide care according to the emerging evidence. Communication via multiple modes is essential to ensure that staff is getting the correct, up-to-date information to counter information from the many unreliable sources. This is best accomplished through daily shift huddles, weekly virtual huddles with administrative leadership, and leadership rounds. Leaders must be authentically present and truly listen to the needs of staff.

Leadership must provide resources to address the staff’s anxiety and emotional distress. It is essential to take an inventory of available program resources (e.g., social workers and neuropsychologists) to provide staff support. Staff may be experiencing multiple stressors as a result of the pandemic, including home schooling children, loss of income of a partner, social isolation for members of the family, and loss of previous leisure activities, in addition to the stressors of working in health care during a pandemic. Employee assistance programs can be promoted to support staff. Facilities may allow flexing shift work times to allow for staff to care for children. Staff can be supported through creating time or opportunity for fun, such as video chat clubs and exercise classes created to allow staff to safely interact with their colleagues before or after work hours.

The ability to provide adequate staffing may be affected by absenteeism as a result of nurses being infected with COVID-19 or the need to provide care to family members who are ill with COVID-19. This may result in staff working excessive overtime, leading to exhaustion and burnout. It may also result in less availability of nurses than needed for safe and high-quality care, leading to burnout among nurses. Leaders must educate nurses on the importance of COVID-19 prevention practices both inside and outside the workplace to minimize absenteeism. In addition, some rehabilitation nurses working in hospital systems have been required to float to medical-surgical units to meet staffing requirements. Some embraced this as an opportunity for growth; however, this created tremendous anxiety for others who did not feel prepared to provide this level of nursing care.

Potential exposure to a patient, family caregiver, or other staff member is a significant stressor for the team. These situations must be managed closely with open, transparent communication. Ensuring access to testing and timely results is extremely beneficial in managing the team’s anxiety surrounding an exposure. Leaders must share community resources for healthcare professionals, such as free hotel rooms for staff who are concerned about an exposure and do not want to introduce risk to their family. Leaders must always support staff in enforcing distancing and mask policies with all present in the facility. More recently, vaccine availability and ambiguity about its safety and efficacy, despite strong empirical evidence, are additional stressors that nurses and the team members may face (CDC, 2021b). It is essential that nurses utilize reliable sources of information, such as the CDC, to stay apprised of the evolving science of vaccine safety and efficacy. Furthermore, nurses must educate patients and family caregivers on the personal and societal benefits of receiving the vaccine.

Finally, self-care for nurses is mandated by the American Nurses Association (2015) Code of Ethics. Leaders must promote self-care for nurses, encourage good nutrition, exercise, sleep and rest, and stress reduction and communicate available resources, such as the American Nurses Association Well Being Initiative (https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/what-you-need-to-know/the-well-being-initiative/) to support these efforts.

Summary

The COVID-19 pandemic continues to impact rehabilitation nurses, the patients and families we serve, and the IRF industry. The situation continues to evolve with the advancement of acute care treatments to minimize debility. Furthermore, an end to the pandemic is on the horizon with the approval of several vaccines by the Federal Drug Administration.

IRF care delivery has been transformed as a result of the pandemic. Rehabilitation professionals saw a need and quickly adapted to restructure care for those in need. Rehabilitation nurses are writing a novel text about IRF care during a pandemic with the ending uncertain. Long-term sequelae are unknown; however, early reports suggest that there may be lasting effects on the mental health of the patient and the family caregiver, in addition to the functional status of those who recover from COVID-19.

Recommendations

We must apply past and future experiences to clinical operations and care delivery and adopt beneficial technology innovations. For example, at the legislative level, the waiver of the 60% rule during the pandemic taught us that the true indicator for the need for rehabilitation services is not the diagnosis but the functional limitations of patients. We can use this information to further advocate for IRF coverage based on patient need, rather than a list of diagnoses. At the clinical level, we introduced many technologies into care delivery. The effectiveness of these modes of family caregiver education and preparation are not known. Rehabilitation nurse researchers must study the structures and processes of care, including the impact of reduced visitation and technology solutions on family caregiver preparation for discharge, readmission rates, and the patient/family adjustment to the disability. At the clinician level, rehabilitation nurses must support family caregivers during the pandemic. For example, they can assist the family caregiver to identify a “bubble” of people who will be able to help them upon their return to home. Rehabilitation nurses must educate families of the availability of COVID-19-related resources, such as those offered through the FFCRA. Leaders must continue to support staff through this crisis through authentic presence and ensuring resources, education, and training. For a list of key recommendations, see Table 2. Collectively, we must synthesize key clinical and administrative experiences and successful practices during this unprecedented time in public health and study the impact of COVID-19 and rehabilitation nursing interventions, including the use of technology, to improve outcomes for patients and family caregivers.

Table 2 - Key Recommendations
Rehabilitation Nurses and Case Managers
• Educate patients and caregivers on the safety, efficacy, and personal and community health benefits of receiving the COVID-19 vaccine
• Assess caregivers for their preparedness for the caregiver role and address any gaps in a tailored plan of care
• Understand and educate patients and families on COVID-19 resources for people with disabilities, such as those offered through the Families First Coronavirus Response Act
• Help caregivers identify a “bubble” of people who will be able to help them upon return to the home.
Nurse Leaders
• Support staff through the crisis through authentic presence and transparent communication
• Stay abreast of the new guidelines and policies
• Ensure the provision of staff education
• Provide resources for managing staff anxiety and emotional distress
• Share community resources for healthcare professionals
• Enforce distancing and mask policies for staff and visitors
• Promote self-care, encouraging good nutrition, exercise, sleep and rest, and stress reduction for staff
• Communicate available self-care resources, such as the American Nurses Association Well-Being Initiative
• Apply learnings to clinical operations and care delivery and adopt beneficial technology innovations
Rehabilitation Nurse Researchers
• Study rehabilitation nursing interventions to improve outcomes for patients post-COVID-19, including technology solutions to decrease social isolation
• Study the impact of visitation restrictions and technology solutions on caregiver preparation for discharge

Key Practice Points

  • Rehabilitation nurse leaders must stay abreast of regulatory changes, recommendations from the Centers for Disease Control and Prevention, and the rapidly emerging rehabilitation management of patients with COVID-19.
  • Rehabilitation nurses must address the COVID-19-related biopsychosocial needs of the patient and family unit.
  • Rehabilitation nurses must utilize technology with visitation restrictions in place to decrease patient/family isolation and maximize family caregiver preparedness and the home transition.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

The authors declare that there is no funding associated with this project.

REFERENCES

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Keywords:

COVID-19; pandemic; rehabilitation nursing; inpatient rehabilitation

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