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Diversity equity and Inclusion: To advance infection prevention and control efforts, nursing assistants need to be given the opportunity to dance

      The poor state of infection prevention and control in both long-term and acute care settings was revealed by the COVID-19 pandemic.
      • Anderson DC
      • Grey T
      • Kennelly S
      • O’Neill D
      Nursing home design and COVID-19: Balancing infection control, quality of life, and resilience.
      In hospitals,
      • Cohen J.
      • Rodgers Y.V.D.M.
      Contributing factors to personal protective equipment shortages during the COVID-19 pandemic.
      personal protective equipment (PPE) was scarce, communication was fragmented, and staff were ill prepared. In nursing homes, these issues were significantly worse.
      • Gibson D.M.
      • Greene J.
      State actions and shortages of personal protective equipment and staff in U.S. nursing homes.
      Nursing assistants are critical to infection prevention and control (IPC) efforts in both hospitals and nursing homes. They spend a significant amount of time in activities that have the potential to reduce or worsen infections, yet their involvement in IPC efforts within each setting has and continues to be fraught. Understanding how to better integrate all nursing home personnel, including nursing assistants, into IPC efforts is necessary to ensure safe and quality care for patients and staff alike. To get there, we must pay attention to how the poor use of nursing assistants in IPC is centered on a limited focus on diversity, equity, and inclusion (DEI) in acute and long-term care settings. As APIC celebrates its 50th year and AJIC celebrates its 50th volume, it is important that those involved with IPC incorporate DEI in their efforts.

      Why diversity, equity, and inclusion?

      Of the nearly 600,000 nursing assistants employed in nursing homes and 380,000 in hospital settings, 50% are from a racial or ethnic minority background, 14% are of immigrant status, and 17% are considered low income.
      U.S. Bureau of Labor Statistics
      Occupational Employment and Wage Statistics.
      • Sloane P.D.
      • Williams C.S.
      • Zimmerman S.
      Immigrant status and intention to leave of nursing assistants in U.S. nursing homes.
      • Ecker S.
      • Pinto S.
      • Sterling M.
      • Wiggins F.
      • Ma C.
      Working experience of certified nursing assistants in the greater New York City area during the COVID-19 pandemic: Results from a survey Study.
      • Kim M.
      • Lin Y.C.
      • Luna G.
      • Ma J.
      • Stiehl E.
      Certified nursing assistants’ barriers and facilitators to accessing and using worksite health promotion programs.
      Despite having important responsibilities in the health care setting with an influence on IPC, such as assisting with bathing, feeding, and toileting, being the eyes and ears of the nurse, and knowing the resident and/or patient best, this workforce is often disrespected, undervalued, underutilized, and excluded from important conversations in the nursing home and hospital setting.
      • Ecker S.
      • Pinto S.
      • Sterling M.
      • Wiggins F.
      • Ma C.
      Working experience of certified nursing assistants in the greater New York City area during the COVID-19 pandemic: Results from a survey Study.
      These experiences among nursing assistants and the subsequent poor outcomes for both residents and/or patients (eg, infections) and nursing assistants (eg, burnout, turnover) can be largely attributed to health care organizations failing to uphold important DEI principles meant to enhance the care and work environment for residents and/or patients and staff who come from diverse and underrepresented backgrounds.

      What is diversity, equity, and inclusion, and how does it relate to IPC?

      Using the University of Michigan's DEI framework, this commentary will define the concepts

      Defining diversity, equity and inclusion. Accessed March 31, 2022. https://diversity.umich.edu/about/defining-dei.

      of DEI in a way that is relevant and makes sense in the context of IPC.
      Diversity is a commitment to increasing the representation of individuals from diverse and/or underrepresented backgrounds (eg, race and/or ethnicity, disability, sexual orientation, gender). It should be thought of as everyone being “invited to the party”.
      With regard to IPC, nursing assistants are often not invited to the party. They do not readily sit in meetings in which their presence is critical (eg, huddles or resident and patient care discussions), and ways for them to contribute to resident care plans are often not standardized.
      • Travers J.L.
      • Schroeder K.
      • Norful A.A
      • Aliyu S.
      The influence of empowered work environments on the psychological experiences of nursing assistants during COVID-19: a qualitative study.
      The intention may be for nursing assistants to be a part of these spaces, however, the nursing assistants being classified as too busy is often used as an excuse for not extending the invitation.
      • Travers J.L.
      • Schroeder K.
      • Norful A.A
      • Aliyu S.
      The influence of empowered work environments on the psychological experiences of nursing assistants during COVID-19: a qualitative study.
      ,
      • Travers J.
      • Herzig C.T
      • Pogorzelska-Maziarz M.
      • et al.
      Perceived barriers to infection prevention and control for nursing home certified nursing assistants: A qualitative study.
      When nursing assistants are not invited to the party, they are not held accountable for IPC efforts in ways that can help them appreciate their potential impact in this area.
      • Travers J.
      • Herzig C.T
      • Pogorzelska-Maziarz M.
      • et al.
      Perceived barriers to infection prevention and control for nursing home certified nursing assistants: A qualitative study.
      During the pandemic, specifically, many decisions around COVID-19 were often made without the input of nursing assistants.
      • Travers J.L.
      • Schroeder K.
      • Norful A.A
      • Aliyu S.
      The influence of empowered work environments on the psychological experiences of nursing assistants during COVID-19: a qualitative study.
      This was also seen through the observed lack of communication with nursing assistants concerning the state of COVID-19. As it relates to safety efforts, such as IPC, poor communication has been found to create fears among nursing assistants.
      • Travers J.L.
      • Schroeder K.
      • Norful A.A
      • Aliyu S.
      The influence of empowered work environments on the psychological experiences of nursing assistants during COVID-19: a qualitative study.
      Inclusion is a commitment to pursuing deliberate efforts to ensure that the organization is a place where differences are welcomed, varying perspectives are respectfully heard, and every individual feels a sense of belonging and inclusion. In other words, everyone gets “to contribute to the playlist”.
      Not only are nursing assistants not invited to IPC-related conversations and spaces, but their feedback and perspectives are often not solicited to support IPC efforts. An example of this relates to the COVID-19 vaccination. Although many decisions were being made around vaccination, nursing assistants were rarely asked to be a part of these decisions. This lack of inclusion fueled mistrust and fear among nursing assistants and the lack of support from leadership left nursing assistants feeling abandoned and upset.
      • Travers J.L.
      • Schroeder K.
      • Norful A.A
      • Aliyu S.
      The influence of empowered work environments on the psychological experiences of nursing assistants during COVID-19: a qualitative study.
      • Travers J.
      • Herzig C.T
      • Pogorzelska-Maziarz M.
      • et al.
      Perceived barriers to infection prevention and control for nursing home certified nursing assistants: A qualitative study.
      • Sadarangani T.R.
      • David D.
      • Travers J.
      Engaging nursing assistants to enhance receptivity to the coronavirus disease 2019 vaccine.
      The failure to include nursing assistants even goes so far as not providing them the necessary resources and support to participate in IPC efforts. In a qualitative study conducted during the early phases of the COVID-19 pandemic, nursing assistants discussed PPE being locked up at night, which restricted their access to critical resources.
      • Travers J.L.
      • Schroeder K.
      • Norful A.A
      • Aliyu S.
      The influence of empowered work environments on the psychological experiences of nursing assistants during COVID-19: a qualitative study.
      Prior to the pandemic, language and culture has been noted as barriers to engaging nursing home nursing assistants in IPC efforts, which such barriers can prevent nursing assistants from being able to understand IPC-related tools and information if not presented in their preferred language.
      • Travers J.
      • Herzig C.T
      • Pogorzelska-Maziarz M.
      • et al.
      Perceived barriers to infection prevention and control for nursing home certified nursing assistants: A qualitative study.
      Equity is a commitment to actively working to challenge and respond to the bias, harassment, and discrimination that occurs within an organization. In other words, everyone should have “the opportunity to dance”.
      Bias, harassment, and discrimination are inherent in the health care setting and are often seen at greater levels in these settings than out in the community.
      • Travers J.L.
      • Teitelman A.M.
      • Jenkins K.A.
      • Castle N.G.
      Exploring social-based discrimination among nursing home certified nursing assistants.
      We see this glaringly in the manner in which nursing assistants are supported tangibly. For example, nursing assistants did not receive the same amount of support as registered nurses and physicians did during the pandemic, such as complimentary hotel stays and hazard pay.
      • Folbre N.
      • Gautham L.
      • Smith K.
      Essential workers and care penalties in the United States.
      This is a clear lack of regard for the financial security and safety of nursing assistants and also shows up in their wages. On average, nursing assistants are paid $16/hour,
      U.S. Bureau of Labor Statistics
      Occupational Employment and Wage Statistics.
      which is insufficient to pay for essential needs, such as rent and/or mortgage, utilities, groceries, and transportation on a monthly basis. Inadequate wages forces nursing assistants to have to work multiple jobs, the consequences of which, in the face of COVID-19, were hefty.
      • Van Houtven C.H.
      • Depasquale N.
      • Coe N.B.
      Essential long-term care workers commonly hold second jobs and double- or triple-duty caregiving roles.
      Nursing assistants working at multiple nursing homes perpetuated the spread of COVID-19 infection and subsequent deaths among residents and staff. Workload is additionally heavy among nursing assistants as a result of staffing shortages; and the subsequent time constraints often restrict nursing assistants’ ability to participate in IPC.
      • Travers J.
      • Herzig C.T
      • Pogorzelska-Maziarz M.
      • et al.
      Perceived barriers to infection prevention and control for nursing home certified nursing assistants: A qualitative study.
      Overworked staff pose a threat to resident safety and quality of care, as the attention of nursing assistants can be diverted from important care areas related to IPC.

      Promising strategies exist to ensure that diversity, equity, and inclusion are reflected in IPC efforts

      There are a number of strategies that acute and long-term care organizations can incorporate to ensure that they are taking a DEI approach when it comes to IPC.
      • Travers J.L.
      • Schroeder K.
      • Norful A.A
      • Aliyu S.
      The influence of empowered work environments on the psychological experiences of nursing assistants during COVID-19: a qualitative study.
      • Travers J.
      • Herzig C.T
      • Pogorzelska-Maziarz M.
      • et al.
      Perceived barriers to infection prevention and control for nursing home certified nursing assistants: A qualitative study.
      • Sadarangani T.R.
      • David D.
      • Travers J.
      Engaging nursing assistants to enhance receptivity to the coronavirus disease 2019 vaccine.
      • Travers J.L.
      • Teitelman A.M.
      • Jenkins K.A.
      • Castle N.G.
      Exploring social-based discrimination among nursing home certified nursing assistants.
      They include:
      • 1.
        Provide education in languages that work best for nursing assistants and ensure that nursing assistants understand the educational material. This can be accomplished by drawing on more visuals and practical experiences and providing information that nursing assistants need in a way that they can understand it. It is also important to identify staff who are part-time and per diem, and ensure they too have access to IPC information. Enabling nursing assistants to engage with information and resources specific to IPC allows them to stay informed and up-to-date.
      • 2.
        Increase staffing, increase wages, and incentivize nursing assistants so that they do not have to work multiple jobs.
      • 3.
        Empower nursing assistants through opportunities for advancement and ensure that bidirectional communication with other health care staff is occurring. Empowerment has been found to increase satisfaction and morale.
      • 4.
        Provide opportunities to nursing assistants by challenging them and allowing them to take on new roles.
      • 5.
        Increase engagement with nursing assistants, include them in the care teams, and involve them in care plans.
      • 6.
        Provide support—mentally, tangibly, physically, and emotionally. Ensure that nursing assistants feel supported by registered nurses, supervisors, and others, that they feel competent in the work that they are doing (such as having access to proper resources and adequate information), and that they have the ability to access protocols and guidelines. Recognize that support comes in different forms, such as feedback and guidance received from supervisors, peers, family, and friends, along with mental support. In the face of short staffing, feelings of support go a long way. Having a resource nurse to whom nursing assistants can go to is important. Create spaces where nursing assistants feel comfortable asking questions or asking for help.
      • 7.
        Make nursing assistants feel appreciated and a part of the team. Ensure nursing assistants feel seen and thank them more. Just talking to nursing assistants or expressing appreciation can be enough. Encourage the team to help each other, as in a state of fear, a sense of teamwork and support provides positive energy.
      • 8.
        Check in on nursing assistants and acknowledge their feelings. Oftentimes, we pay attention to registered nurse and physician burnout, for example, but not to the burnout experienced among nursing assistants. Ask nursing assistants if they are OK.
      In this commentary, I have provided considerations for the gaps in DEI specific to IPC and strategies to fix these gaps. While this list of strategies to improve IPC efforts using a DEI approach might not be exhaustive, this is an important start to ensure that nursing assistants are invited to the party, are able to contribute to the playlist, and have the opportunity to dance to the tunes. It is important to note, the benefits of achieving DEI for nursing assistants extend beyond improved IPC.

      References

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