Approximately 4.5 million people with developmental disabilities reside in the US 1 and represent a population at high risk for severe health outcomes from COVID-19 2 . A developmental disability (DD) represents a broad group of conditions that originate before age 22 , are expected to last a lifetime, and result in significant impairments in physical or mental functioning, impacting day-to-day living and necessitating supports and assistance 3 . Examples of DD include autism, cerebral palsy, Down syndrome, intellectual disability, and congenital blindness. Emerging data from states indicate that people with DD have higher case fatality rates from COVID-19 than people without disabilities. In New York, the COVID-19 case fatality rate for people with DD who are receiving services is 2.2 times higher than the overall COVID-19 case fatality rate 4 . In New Jersey, more than a third of the 1,238 people living in its five state-run residential facilities for people with DD have contracted the virus, which has already killed 27 people 5 . A lack of national surveillance data related to people with DD challenges our understanding of the impact of COVID-19 among persons with DD in the US population. Data from the health records of 42 academic medical centers worldwide found that people with DD have a higher prevalence of comorbid conditions associated with poor COVID-19 outcomes and a higher case fatality rate at younger ages, as compared to persons without DD 6 .
These disparate COVID-19 outcomes are not surprising given the health disparities faced by people with DD at baseline prior to the pandemic, including poorer health outcomes 7 , limited access to needed health care services 8 , participation in fewer prevention and health promotion activities 7 , increased risk for chronic health conditions 7 , and earlier age of death when compared to the general population 9. In addition, people with DD have a higher prevalence of specific comorbidities associated with poor outcomes from COVID-19, including diabetes, hypertension, heart disease and respiratory disease 6 . People with DD are more likely to be obese and experience polypharmacy 10 , contributing to increased risk for poor COVID-19 outcomes 11 .
Mortality rates from pneumonia, a frequent complication of COVID-19, are also higher in people with DD compared with the general population 4 . Furthermore, people with DD face high rates of hospitalizations and increased iatrogenic complications as compared to those without DD 12 .
Despite their vulnerable and high-risk status, our search in March 2020 of the CINAHL, MEDLINE, and PsychInfo databases identified no studies exploring the impact of COVID-19 in people with DD. Our search terms included: "COVID-19" adding developmental disability, J o u r n a l P r e -p r o o f intellectual disability, disabilities, disabled person, person with disability, group home, and congregate living.
Models of care for people with DD have shifted over time in response to societal demands. Historically, people with DD were segregated from society in large, state-run institutions which often lacked adequate resources to meet the basic needs of people with DD and were characterized by pervasive, systemin neglect and abuse 3 . As a result of media exposure and class action lawsuits in the 1960's and 1970's, legal challenges to institutional care mounted and states were forced to find community-based alternatives to institutional care, a movement known as deinstitutionalization 13 . The first federal support for DD care came in 1972 with the authorization of Intermediate Care Facilities for Intellectual Disabilities (ICF/IID) 13 . These Medicaid funded institutions consist of 4 or more beds for individuals with intellectual disability or related conditions and provide active health or rehabilitative services that meet specific standards of care 14 waivers allow states the flexibility to provide care in smaller, more individualized home and community-based settings, including group homes, supervised apartments, foster homes, supported living settings, and the family home 13 . More specifically, the HCBS waivers allow for a wide range of health and human services to be provided in home and community-based settings, including, but not limited to skilled nursing care, occupational, physical, and speech therapies, personal care assistance, case management, legal and financial services, and habilitation (daily living skills) training in both day programs and residentially 16 . All 50 states currently participate in the HCBS waiver program 13 , and the majority of public funding for DD care is now provided through HCBS waivers 17 .
Unfortunately, the persistent health disparities faced by people with DD are illustrative of the large gap that remains to achieving equitable care for people with DD. The current health care system for people with DD residing in the community can be characterized as fragmented, uncoordinated, and difficult to access, with more heath care providers lacking appropriate education and training to meet the unique care needs of people with DD 18 . The inability of community settings to adequately meet the needs of people with DD represents a social J o u r n a l P r e -p r o o f determinant of health, which are personal, social, economic and environmental factors that influence a population's overall health status 7 . DD nurses, as registered licensed and practical nurses who provide nursing care and support to individuals with DD 19 , play a critical yet complex role in filling the health care gap for people with DD. DD nurses care for people with a wide scope of DD often accompanied by chronic co-morbidities and multifaceted care needs across a growing diversity of care settings 20 Ultimately, DD nurses act as an essential liaison between the disparate health care and disability service systems.
DD nurses also collectively face unique challenges in meeting the care needs of people with DD, including addressing stigma associated with people with DD and ensuring that care is responsive to the unique needs of people with DD given the inadequate disability knowledge and training of the health care team 20 . DD nurses also face tension from within the disability community as they balance health care needs with concerns related to a medical model of care 20 .
The nursing profession as a whole is firmly established within a medical model of care, which views disability as an illness or abnormality within the individual, requiring expert healthcare professional intervention 20 . The concern is that a focus on medical care needs will restrict the freedom of persons with DD to live, work, and recreate in the least restrictive setting. In reality, DD nurses' practice is guided by a person and family-centered model of care 21 
A convergent parallel mixed methods design was used 23 , meaning that both quantitative and qualitative data were collected concurrently, through an on-line survey. We identified the need to compare and converge both types of data to gain insight into an unprecedented problem like pandemic impact and preparedness.
The target population for this study was licensed or registered nurses currently providing, directing, consulting, or managing care of people with DD in the United States. Retired nurses, unlicensed student nurses or caregivers, and those not currently practicing DD nursing were excluded. Nurses were recruited via emails sent to all 954 nurse members of the Developmental Disabilities Nurses Association.
Ethics approval was obtained from the University of Massachusetts Dartmouth. The email invitation consisted of an invitation to participate in an online study, a description of the study's purpose, inclusion and exclusion criteria, and the link to the study. We also included a statement requesting the nurse share the email with other DD nurses in their personal and professional networks to minimize bias associated with all respondents belonging to a professional nursing organization. Implied consent was obtained from all participants based on a cover letter included on the first page of the survey that described the study and asked potential participants to click "yes" if they agreed to participate. Those who agreed to participate were then routed to the first page of the survey. The survey was open from April 6 th to April 20 th , 2020. A reminder was sent to all who did not open the email on April 10 th , and a reminder was sent to all members at one week.
The survey was developed based on a review of the literature on disaster and emergency items asked nurses to rate the degree to which they have faced or anticipate facing challenges in the care of persons with DD as a result of the COVID-19 pandemic. These items were rated using a 5-point Likert scale anchored with endpoints 1-"not at all" to 5-"extreme" and were grouped into four care areas: health needs, social needs, service needs, and COVID-19 actions.
One additional open-ended item asked nurses to list or describe any other challenges or anticipated challenges to meeting the needs of people with DD as a result of the COVID-19
pandemic.
Descriptive and inferential statistics described and analyzed the quantitative data using IBM SPSS software 25 . All data were evaluated for applicable statistical assumptions. The Because we were interested in the granularity in challenges faced by DD nurses and not summarizing an overall level of challenge, mean scores were calculated for each item and independent t-tests were used to compare mean item scores between those who had cared for an individual testing positive for COVID-19 and those who had not. ANOVA was used to test for statistically significant differences in the mean item scores based on geographic region. As we were not interested in characterizing an overall level of challenge faced by nurses, we did not sum the item scores to analyze as a scale, thus missing data was not a concern and all available data were analyzed for each item.
Manifest content analysis 26 was applied to the open-ended survey responses. This qualitative data analysis approach seeks to describe the surface structure of the data, asking "What has been said" 26 Table 3 presents the results of independent samples t-tests comparing COVID positive and negative conditions. A key issue between the two groups was COVID-19 planning.
Significant differences were noted in the ability to develop an emergency plan for an individual or agency, with significant associated challenges with contact tracing and quarantining suspected or confirmed cases. In the open-ended responses, several nurses reported that they were excluded from COVID-19 planning in their agencies and were advised to "stay out of staffing".
Significant differences were also noted in the ability to maintain adequate staffing levels for direct care staff and nursing. Open-ended responses revealed an overburdened DD workforce, with many staff working in multiple residences, leading to concerns of "cross-contamination" of staff and increased risk of COVID-19 for supported persons with DD.
Illustrative examples from the qualitative data supporting the quantitative findings are included in Tables 2 and 3 . There were no significant differences in item mean scores based on geographic region.
Challenges identified by the nurses' open-ended responses were categorized according to socioecological level in Figure 1 . The open-ended responses revealed challenges at all levels, with many challenges being experienced beyond the traditional clinical work setting of the nurse, involving organizational, community and policy-level influences. A critical challenge identified by the nurses is the lack of national and state policies and guidance specific to DD care settings.
Persons with DD are a high-risk and overlooked population during the COVID-19
pandemic. This theme is also noted in the disability-oriented press 27,28 . Numerous multi-level challenges exist to the ability of DD nurses to meet basic care and support needs of people with DD. The pandemic has left DD nurses feeling stressed, fearful, depressed, and burned out, and simultaneously wishing they could do more to help. DD nurses are emotionally invested in the care they provide and struggle with balancing their passion and enthusiasm with stress, guilt over their limitations, and feeling devalued in their role even prior to a pandemic 29 . Nurses need ongoing support and strategies to address the physical and psychological impact of working during a pandemic 30 , and this need extends to DD nurses who have been described as marginalized from the nursing specialty 20 . In the words of one respondent "we are at the front line trying to keep consumers and staff safe and feel alone." It is now more important than ever that DD nurses are supported physically and psychologically to practice at their fullest potential.
Beyond acquiring supplies of PPE and sanitizers, nurses identified that the greatest challenges faced were related to the interpersonal/social impact of COVID-19 on people with DD, as well as their caregivers and families. Nurses overwhelmingly identified helping people to understand as a critical aspect of their role, including helping people with DD and their support staff to understand the reasoning behind routine changes, visitation limitations, use of PPE, and social distancing. Helping people with DD to understand these changes is especially important as DD nurses described a dramatic increase in challenging behaviors as a result: "Basically everything we try to do, every day, turns into a challenge. Our individuals' behavior(s) are exacerbated by having to remain home in close quarters, they are frustrated, confused, angry, J o u r n a l P r e -p r o o f disoriented, perplexed, bewildered, and every other adjective and do not know how to handle it.
We are seeing behaviors we have never seen before, in people we have never seen them in before and staff are trying to cope and deal with them." Along with an increase in challenging behaviors, increased use of psychiatric medications was reported, which given known polypharmacy risks in people with DD may contribute to additional risk for negative outcomes from COVID-19 11 . In some instances, DD nurses' ability to intervene was limited by physical distancing and decreased access to persons with DD in their homes. They described having to connect with people with DD over Zoom, and even managing client medications by having staff drop off and pick up medications outside the nurse's home. Given that DD nurses possess a unique relational skill set 31 characterized by a strong nurse-client relationship 29 , continued access to a DD nurse is a critical resource to assist people with DD to cope with change in a healthy manner. DD nurses can provide leadership on programming to address mental health issues, reduce challenging behaviors associated with pandemic-related changes, and maintain a healthy, balanced lifestyle during the pandemic.
DD nurses also face challenges to meeting the needs of people with DD from within their employing organizations. Several nurses indicated that they are not involved in pandemic planning that takes place at their agencies and are even purposefully excluded and told to "stay out of staffing business". This is particularly important as determinations about who is considered "essential personnel" are made for vulnerable persons with DD and complex health conditions residing in community settings by those with little health care knowledge or background. Furthermore, organizations are challenged to maintain adequate staffing and onboard new staff with appropriate hands-on training to care for people with complex needs during a pandemic, while social distancing necessitates only virtual trainings. As many health care offices are closed or limiting access due to COVID-19, and more complex care is being provided in home and community-based settings, it is imperative that persons with DD have access to the appropriate level of knowledgeable staff who are responsive to their unique needs.
Inopportunely, the chronic shortage of direct care staff in home and community-based settings 32 is exacerbated during the COVID-19 pandemic as DD nurses report staffing challenges related to staff exposure and quarantine, as well as fears of contracting the virus. In the absence of adequate staffing, care staff are covering multiple residences and working for multiple agencies, increasing the risk of "cross-contamination" and spread of COVID-19. DD nurses J o u r n a l P r e -p r o o f report that direct care staff have expressed concern over working during a pandemic as many direct care staff have health conditions that place them at high risk. The majority of the direct care workforce is female, of color, middle-aged or older, and reliant on some form of public assistance, with 1 in 5 lacking health insurance 33, 34 . This means that this "invisible COVID-19 workforce" is itself at higher risk for COVID-19 due to racial 35 and socioeconomic health disparities 36 .
DD nurses participating in this survey recognize the need for the enactment of policies that identify DD care workers, including nurses and direct care staff, as front-line health providers. Nurses describe that PPE is diverted to other "health care workers, as if we do not provide health care as a basic service". Testing has not been prioritized for individuals living and working in group homes, despite the increased risks of congregate living. Furthermore, hazard pay has not been extended to most DD care staff, heightening the short staffing situation experienced even prior to the pandemic. DD nurses also describe their frustration with the lack of policies and guidelines specific to the DD setting from public health and governmental bodies, and the lack of inclusion of DD nurses in ongoing COVID-19 administrative planning and policy decisions. This is despite the fact that DD nurses possess the education, experience, and skillset to not only participate in, but also lead interprofessional healthcare teams. As both healthcare and disability experts, DD nurses can provide leadership to tailor public health guidelines for use in specific DD settings. DD nurses can also educate non-health care staff with factual information on relative risks of COVID-19 and infection control practices, to help counteract widespread social media misinformation contributing to fear, stress, and anxiety.
In the face of COVID-19, the results of this study magnify the consistent issues relevant to the ongoing care and support needs of people with DD. The large sample size and lack of statistical differences between regional areas suggest that findings are generalizable nationwide. Furthermore, given this population of people who often live in congregate, community-based settings, they are particularly vulnerable and at high-risk for adverse outcomes within emergent and pandemic situations. Study limitations include a) self-selection of nurses belonging to a specialty nursing organization, and b) the cross-sectional design which captures nurses' experiences at only one point during the ongoing pandemic. Findings reflect the challenges faced and anticipated by DD nurses early in the pandemic response which may bias findings toward J o u r n a l P r e -p r o o f magnifying challenges associated with pandemic planning over actual COVID-19 prevention and risk mitigation activities.
As health care for people with DD has shifted from an institutional model to care provided in a variety of home and community-based settings, the role of the DD nurse so, too, has diversified. A lack of clear understanding of the DD nursing role and agencies' lingering concerns over medicalizing disability care 20 were evident in nurses' descriptions of challenges faced in meeting the care needs of people with DD during the COVID-19 pandemic. Future research needs to specifically address and incorporate the role of the DD nurse as a critical participant in the interprofessional team, which is especially important during a health care crisis.
Additionally, although nursing is often associated with the medical model of disability20, DD nurses in this study most highly ranked social considerations to meeting the needs of people with DD, supporting a social model of health. Such a model provides a framework for research relevant to social determinants important to health and wellness in the daily lives of people with DD, as well as during a pandemic.
Staff working in DD residential agencies provide 24/7 care to individuals at high-risk for complications from COVID-19. Ready availability of PPE must be prioritized for these settings.
Likewise, testing needs to be prioritized for people with DD and their care staff. Public health guidelines specifically inclusive of DD residential and day habilitation settings are needed.
Increased funding, including hazard pay for direct care staff, is needed to mitigate overwhelming staff shortages. DD nurses need to be involved in pandemic planning at every level to ensure basic care needs, including physical and mental health, social, and spiritual needs, are being adequately met to prevent and mitigate the spread of COVID-19 and adverse consequences associated with social distancing and isolation. J o u r n a l P r e -p r o o f 