INTERPROFESSIONAL ROLES AND COLLABORATIONS TO ADDRESS COVID-19 PANDEMIC CHALLENGES IN NURSING HOMES

Nursing home experts and informatics nurses collaborated to develop guidelines for nursing homes that revealed partnership principles in action during the COVID-19 pandemic. This article describes efforts to define interprofessional nursing home staff roles within the partnership-based COVID-19 Response Guideline, and to examine changes in nursing practice compared to the pre-pandemic practice of nurses. The qualitative process of identification of nursing home staff roles revealed the extensive scope of interprofessional partnership needed to respond to the pandemic. Using the Omaha System structure, we compared these collective COVID-19 response interventions of Nursing Service roles with nursing interventions of RNs and LPN/LVNs defined in previous nursing home studies. This comparison showed the necessary transformation and collaboration among nurses needed for the pandemic response in nursing homes. The Omaha System Pandemic Guideline is available online and in the Omaha System Guidelines app for immediate use as COVID-19 response practice guidelines and references for interprofessional roles in nursing homes, as well as for multidisciplinary roles across diverse care settings. The guideline is an exemplar of how informatics can facilitate interprofessional and multidisciplinary partnership for nursing homes and other care settings. Future use of the guidelines for decision making and documentation related to infection prevention and control in nursing homes may improve care quality and health outcomes of residents and population.

In addition to insufficient financial and human resources and supplies, congregate living and physical layouts made nursing homes more vulnerable to COVID-19, turning them into ground zero for the COVID-19 pandemic Barnett & Grabowski, 2020;Davidson & Szanton, 2020;Grabowski & Mor, 2020;Kolanowski et al., 2021). A new care model was needed immediately to support nursing home employees, who were struggling to achieve infection control and manage the crisis with limited resources (Grabowski & Mor, 2020;Kolanowski et al., 2021;Levine et al., 2020;Stall et al., 2020;White et al., 2021).
To help mitigate this abrupt and radical shift, nursing home experts and informatics nurses adopted the perspective of partnership systems, which pursues societies based on mutual respect, responsibility, and caring relationships (Eisler, 1989). In contrast to top-down domination systems, partnership systems encourage mutual respect, responsibility, and benefits across hierarchies (Eisler, 2021). Nursing homes are a highly regulated environment with hierarchical care roles delineated by federal and state laws (Requirements for States and Long Term Care Facilities, 2015). Prior to the pandemic, each discipline had separate care goals and carried out different and clearly specified responsibilities for resident care. However, as the pandemic unfolded, nursing home staff combined forces to integrate care responsibilities across roles to save lives and deliver quality resident care.  Produced by University of Minnesota Libraries Publishing, 2022 3

The Omaha System Guidelines
When COVID-19 was declared a pandemic by the World Health Organization (WHO) in March 2020, the Omaha System-encoded evidence-based multidisciplinary guideline for the COVID-19 response was developed based on U.S. Centers for Disease Control and Prevention (CDC) and WHO sources (Monsen, 2020). This COVID-19 Response Guideline was an extension project of the Omaha System Guidelines project, which had been initiated to encode and disseminate evidence-based multidisciplinary practices for client care (Monsen et al., 2011;Monsen et al., 2012;Omaha System Guidelines, 2021;Slipka & Monsen, 2018;Monsen, 2020

The Omaha System and its Applications in Nursing Home Practice
The Omaha System is a standardized terminology for comprehensive practice, documentation, and information management of client care that has been recognized by the American Nurses Association since 1992 (Martin, 2005). It consists of three related components: a Problems Classification Scheme, an Intervention Scheme, and a Problem Rating Scale for Outcomes, all of which enable a comprehensive health assessment and description of multidisciplinary practices across healthcare settings (Martin, 2005) (see Figure 1). It is available in the public domain and has been widely used in community care settings, generating valuable data through documentation during the course of routine practice (Monsen et al., 2019).  (Kang et al., in press, see Appendix 1). These interventions were used as the basis of a time and motion study to observe workflow in a nursing home (Kang et al., 2021). The study showed that RNs and LPN/LVNs focused mainly on medications, communication with the care team, and conversations with residents and family, but relatively less on infection control and prevention (Kang et al., 2021). The study also confirmed a high degree of time pressure with a median intervention time of 32 seconds, an average of 66 interventions and 28 location changes per hour, and multitasking for 30% of total intervention time (Kang et al., 2021).
At the inception of the COVID-19 outbreak, significant changes in interventions for resident care would be expected, to implement infection prevention and control training and measures (Scopetti et al., 2021). In addition to the increasing work demands, nurse shortages and lack of RNs with geriatric nursing and leadership competencies further exacerbated nursing workload Davidson & Szanton, 2020;Kolanowski et al., 2021;Scopetti et al., 2021;White et al., 2021).
Therefore, fostering cultural change from patterns of domination to relationships of partnership among nursing home staff was critical for successful management and surveillance of COVID-19 (Kennedy Oehlert, 2015).
Nursing home experts and Omaha System researchers collaborated to support this cultural change. They identified and defined the interprofessional nursing home staff roles for the collective COVID-19 response. They also investigated changes in the care responsibilities of RNs and LPN/LVNs during the COVID-19 pandemic compared to responsibilities defined prior to the pandemic. This article describes efforts to define interprofessional nursing home staff roles within the partnership-based COVID-19 Response Guideline, and to examine changes in nursing practice from pre-pandemic practice of RNs and LPN/LVNs.  Table 1).  Next, the Stratis team and the Omaha System researchers employed a two-phase qualitative process (mapping and expert consensus) to define collaborative nursing home staff practice for the COVID-19 Response Guideline. Each nursing home expert independently mapped all activities in the guideline to the scope of practice for each of the proposed nursing home staff roles, assuming they were practicing to the top of their license or certification. All experts then shared and discussed their independent findings until consensus about the roles and interventions was achieved. The results were proposed to the Omaha System Community of Practice during an international webinar, consistent with the crowdsourcing techniques used to develop the COVID-19 Response Guideline.

Aim 2: Examine Changes in Nursing Practice Compared to the Pre-pandemic Practice of RNs and LPN/LVNs
To examine the changes in nursing practice during the COVID-19 pandemic, the Nursing Services role defined in the COVID-19 Response Guideline by the Stratis team was compared to the pre-pandemic nursing practice defined in the previous study (Kang et al., in press). The Nursing Services role was based on partnerships among RNs,  (Martin, 2005). The Intervention Scheme describes interventions in a multilevel hierarchy of categories (priority areas of practice), targets (care action), and care descriptions (further specifying the action) (Martin, 2005;Monsen et al., 2011). Each evidence-based intervention is encoded with a single problem, category, target term, and specific care description for resident care.

Aim 1: Define Interprofessional Nursing Home Staff Roles
A new set of six nursing home staff roles and 112 interventions encoded using the Omaha System was added to the COVID-19 Response Guideline (see Table 2). Of a total of 117 interventions included in the guideline    (9), sickness/injury care (7%), medical/dental care (4%), interaction (4%), and coping skills (4%).

Aim 2: Examine Changes in Nursing Practice Compared to the Pre-pandemic Practice of RNs and LPN/LVNs
A total of 90 nursing home COVID-19 response interventions that were specific to the Nursing Services roles were compared to the 57 nursing interventions from the previous study (Kang et al., in press, Appendix 1). Of the 90 COVID-19 response interventions, 16 overlapped with the nursing home interventions before the pandemic (Figure 2). The Omaha System categories and targets remained the same for these interventions, but care descriptions were adapted for the COVID-19 response.  Given the comprehensiveness of the guideline, it may serve as an efficient tool for educational purposes, either for internal protocol updates or for personal learning (Levine et al., 2020;White et al., 2021). Additionally, when the interventions are incorporated within health information technology, they can serve as care protocols and documentation templates as well as generating structured data for further analysis (Martin, 2005;Monsen, Swenson et al., 2017;Monsen, Vanderboom et al., 2017).

Extensive overlapping of interventions across roles (about 40% of interventions)
indicated that it is critical to demonstrate partnership principles among the interprofessional roles and promote cohesive care delivery for effective COVID-19 management with limited resources Kolanowski et al., 2021;Levine et al., 2020;Scopetti et al., 2021;White et al., 2021). This culture change in nursing homes persisted well into the COVID-19 pandemic. Furthermore, the response, indicating the immense pressure that the pandemic has added to frontline nurses in nursing homes. Nurses were required to immediately triage and transfer residents, identify contacts of sick residents and staff, assess symptoms and signs of COVID-19, provide testing and critical care to residents, manage PPE and supplies, and teach PPE protocols and quarantine guidelines (Scopetti et al., 2021;White et al., 2021). To enable quality care under this pressure, individuals' behavior and organizations' cultures will need to change toward intra-and interprofessional   Correspondence about this article should be addressed Yu Jin Kang at ykang47@emory.edu