January 13, 2026
McKnight's Long-Term Care News
Even well-established infection control policies are often abandoned — or at least deviated from — when put into practice during nursing home flu and COVID outbreaks, according to a new study.
Researchers in the Netherlands monitored the progression and management of 24 outbreaks in nursing homes there, ultimately selecting seven for extensive monitoring of practices including symptom-based testing, isolation, use of personal protective equipment, visitor restrictions and cancellation of group activities.
“Organization-wide IPC protocols were often too general and insufficiently tailored to the diverse contexts within nursing homes,” the team reported in JAMDA Jan. 10. “Inconsistent guidance compelled staff to adapt protocols based on situational judgment. These findings raise critical questions about the role of individual decision making in outbreak management, particularly regarding the factors that influence nursing home staff’s choices and whether similar and consistent decisions would be made under comparable circumstances.”
Room isolation decisions, in particular, varied widely across the seven outbreaks. While most staff interviewed viewed isolation as effective at preventing infections, leaders differed in how they balanced its benefits against impacts such as restlessness and agitation, as well as practical feasibility given staffing levels or a resident’s independence level.
“These differences shaped diverse approaches,” the researchers found. “Some strictly implemented isolation even when most residents were already infected or extended isolation durations. Others adjusted measures due to visible resident distress or gradually questioned effectiveness.”
Across interviews, they emphasized the need to “tailor” isolation to individual circumstances, even when that meant deviating from protocol. On the 42 units affected by the closely studied outbreak, 60% used isolation.
Meanwhile, only 52% of units canceled all activities.
And while consensus existed to limit visitor restrictions, the researchers also found complete bans were avoided by decision makers, who considered protective benefits less powerful than the potential “social harm” for residents. In the end, just one-third placed visitor limitations.
Symptom-based testing, however, was used by 100% of the units.
PPE protocols also were broadly implemented with little discussion, but frontline staff reported inconsistent compliance, expressing doubt about their effectiveness because of high attack rates, residents’ inability to distance or the behavior of other staff. In all, 60% of units used PPE on the entire unit if any residents were ill.
The researchers found that managers and geriatricians aimed to balance the impact and protective value of infection control measures, but their individual assessments and priorities varied. That led them to adjust practices throughout the duration of an outbreak.
“Although these adjustments may have mitigated negative consequences, they also carried the risk of increased viral transmission and adverse outcomes,” the study concluded. “These findings underscore the need for proactive, context-sensitive IPC planning that takes the realities of care delivery in diverse settings into account. Without such preparation, staff are left to make complex ethical decisions under pressure, which can lead to inconsistent practices, moral distress and suboptimal outcomes for both residents and staff involved.”