Background
Methods
Design
Participants and recruitment
Data collection
Data analysis
No | Codes |
---|---|
1 | Description of the situation |
2 | Changes due to the specifications |
3 | Implementation of the requirements for cohorting/isolation |
4 | Effects of contact restriction on daily activities |
5 | Measures to promote social participation and quality of life |
6 | Interaction + communication regarding the measures |
7 | Changed effort due to pandemic |
8 | Emotional consequences |
9 | (Current) challenges posed by the pandemic |
10 | Support needs |
11 | Personal protective equipment and disinfectants |
12 | Demands on politics |
13 | Public image/esteem |
14 | Consequences |
15 | Responsibilities |
Results
Participants
Nursing home managers
(
n
= 40)
|
Ward managers
(
n
= 38)
| |
---|---|---|
Work experience in years | 22.4 (± 9.6) | 20.0 (± 10.1) |
Work experience in current function in years | 10.2 (± 8.9) | 8.9 (± 6.9) |
Experience with infectious diseases that required advanced measures | 40 (100) | 37 (97.4) |
Nursing home (n = 43) | ||
Type of nursing home provider | ||
Public | 2 (4.6) | |
Welfare | 30 (69.8) | |
Private | 11 (25.6) | |
Number of beds per nursing home | 96.8 (± 33.9) | |
Nursing homes with specific nursing focus according to the care contract with the statutory long-term care insurance | ||
Dementia | 8 (18.6) | |
Gerontopsychiatry | 1 (2.3) | |
Mental disabilities | 1 (2.3) | |
Mechanical ventilation | 1 (2.3) | |
Persistent vegetative state | 1 (2.3) | |
Others | 5 (11.6) | |
Nursing homes with confirmed COVID-19 infections cases among residents | ||
No | 33 (76.7) | |
Yes | 7 (16.3) | |
Not reported | 3 (7.0) | |
Number of infections per nursing home | 6.1 (± 15.9) | |
Nursing homes with confirmed COVID-19 deaths among residents | ||
No | 34 (79.1) | |
Yes | 6 (13.9) | |
Not reported | 3 (7.0) | |
Number of deaths per nursing home | 1.3 (± 3.7) | |
Nursing homes with confirmed COVID-19 infections cases among staff | ||
No | 27 (62.8) | |
Yes | 13 (30.2) | |
Not reported | 3 (7.0) | |
Number of infections per nursing home | 2.3 (± 5.9) |
Themes for organisational and direct care levels
Challenges and strategies for the organisational level
Theme 1: Appointing a multi-professional crisis task force
“And we meet at least twice a week, when new guidelines or regulations come in, when there is something new, then spontaneously more often and really, it has really proven itself. In the meantime, it has become a really great group, the facility management is there, the housekeeping management, me as the nursing service manager and hygiene officer, and we also sometimes include ward management when something is going on on the ward and needs to be discussed or clarified. And that makes perfect sense to sit down together.” (02_EL_05)
Theme 2: Reorganizing the use of building and spatial structures
“We thought about it for a very long time because we had to create infection areas and quarantine areas. That we have to turn double rooms into triple rooms, single rooms into double rooms. Because how else are you supposed to separate the areas?! Because we are not a hospital. We don't have any locks, do we? We don't have any extra rooms and that was a real challenge for us.” (06_WBL_07)
Theme 3: Continuous adaption and implementation of hygiene plans
"Basically, these are measures that we all know and can carry out, that we have all standardised, and that we now only have to apply permanently, in other words, this specialised hygiene has now become basic hygiene for us.” (02_EL_05)
Theme 4: Adapting staff deployment to dynamically changing demands
“[…] now in such a crisis, to fall back on outside employees, to familiarize them with the processes, um, I think is quite difficult." (09_EL_02)
Theme 5: Managing additional communicative demands
“[…] each living area got a tablet, so that you can skype and […] make appointments also with relatives […]. That is very well received. Where the grandchildren can then also contact the grandparents. We also have received additional smartphones that can be called and WhatsApp to send photos back and forth.” (06_EL_02)
"But really the flow of information about changes, changes in laws and regulations, that was quite, quite annoying, quite difficult.” (04_EL_02)
Theme 6: Relying on and resorting to informal networks
“We [asked] a social support worker who sat down at the sewing machine and sewed masks.” (05_WBL_03)
“So there’s a distillery near us, they made disinfectant liquids there.” (07_WBL_03)
Challenges and strategies for the direct care level
Theme 1: Changed routines
"For example, the room service was very time-consuming. That's four meals a day and then in every room, with setting the table, covering the table, bringing it to the next room when requests are made.” (03_EL_04)
Theme 2: Taking over non-nursing tasks
"Now, for example, with the visitors, we have to get them in, we have to keep exact records and check again how long they are in the rooms. That's all, it takes an insane amount of time and now you realise that they [nursing staff] can't do it anymore." (04_EL_02)
Theme 3: Increased medical responsibility
"And with the physicians, the communication, that was also there in principle, so they then, that now also came more from the physician´s side, they then said, so really only if something is very urgent, we now come to the nursing home. Otherwise, everything was clarified by telephone, or, if it was urgent, i.e. something where the physician said, here, immediately admitted to the hospital, the people, right?" (07_WBL_03)
Theme 4: Increased documentation demands
"Yes, we had to record, for example, in the documentation, we had to measure the vital signs twice a day for a fortnight, temperature, blood pressure, pulse, breathing rate, oxygen content in the blood. That also had to be documented, that is already an additional effort for a complete residential group with 17 residents, to do that twice a day and to document it accordingly." (06_WBL_02)
Theme 5: Promoting social participation
"But yes, we all tried to bridge the gap somehow or to sit down in the [residents´] room and read a bit or do something." (05_WBL_03)
Theme 6: Increased communication demands
"Yes, you can definitely tell by the eyes if someone is smiling or if they are in a bad mood, but for the residents it was hard to tell [through the masks]. And it's still the case that they have to ask several times because many people look at the mouth and can understand by seeing and hearing what we want to do with the resident. So that is difficult." (03_WBL_03)
Supporting factors for the work at organisational and direct care levels
“Quite simply, being there for each other is important and as long as you support each other […] because if that's not the case, then it's very difficult, of course. […] But as long as the cooperation is as good as it has been so far, that people support each other, I don't know what I could say as support. We just hope that this time will also be over at some point.” (06_WBL_04)
Consequences of the challenges and strategies in nursing homes
Positive consequences for nursing home managers and staff
Theme 1: Resources for the challenges
"…that was of course quite exciting, but the first time I must say, when no one came any more, no visitors either, and that was a nice time, you could work off a lot of things that were left lying around, because there were few calls and also no quality audits by the Medical Service of the health insurance, no care classification in that sense." (01_EL_03)
Theme 2: Positive emotional consequences for nursing home managers and staff
"…so among ourselves I would say that we have actually coped well and have actually strengthened ourselves as a team, (…) I would say that we have also strengthened ourselves a little bit." (07_WBL_03)
"We might have a bit more time to go through the rooms. Because the whole work situation is a bit quieter. No contact from the outside. That is something different. You can deal with the people there in a different way." (05_WBL_03)
"Because especially here in the area of dementia, everything is about touching, guiding, closeness, physical closeness. Even taking people who are crying in your arms and yes, you can't always keep the safe distance of 1.5 m and that affects you.” (06_WBL_02)
Negative consequences for nursing home managers and staff
Theme 3: Psychological stress for all facility employees
"Or, for example, relatives say: ´I don't know anyone who died of COVID-19´ or ´how high is the danger, since there are so many infected people now, that something will be brought in here? You staff can also carry it in.´ For example. That's also hard for the staff to bear and for me too." (06_EL_04)
Theme 4: Negative emotional consequences
"Well, that's a bit shocking then. No? That you get NOTHING from the doctors and no real information from the health authorities.” (07_EL_03)
Theme 5: Permanent feeling of responsibility
"But I have never been or felt so in the forefront and in charge, with all the consequences." (06_EL_02)
"But to have this feeling, that is what ALL staff members said, that they are somehow afraid of getting the virus and maybe infecting some resident. (…) To have the guilt, maybe I am the one who is to blame, that the residents are tested, that quarantine comes, that everything is closed again. That always floats along." (06_WBL_07)
"In normal times, you would say that this [inadequate medical care and lack of availability of protective equipment] is failure to render assistance." (05_WBL_03)
"As I said, medical care and also overall care has of course deteriorated massively for the residents." (03_EL_01)
Theme 6: Increased potential for conflict
"Of course we also had a few relatives, we also have rooms here in the basement or behind the house. The ground floor is also at ground level. They simply came in via the terrace. Yes. Again and again they were lectured and spoken to: We're not allowed to and in general. Yes, but my mother lives on the ground floor. I could go and look for her. Yes. So that was a bit of what made everything difficult. You always had to look out: Now there's another visitor. How does that work? Yes. Unreasonable relatives. That was actually the worst thing." (05_EL_02)
"We just don't have a lobby. And THAT'S so sad and THAT'S what we're seeing again in the crisis." (07_EL_03)
"This networking of the entire inpatient care facilities has been lacking, that has to be said, and I think it was also a topic in the media once and there was this headline ´Care must finally deliver´, where we said: yes, we deliver all the time." (02_EL_05)
After easing restrictions
"I have to say that the residents have come to terms with it, I don't want to say that, but we have residents who lived through the war. And now they come and say: 'Actually, we're still doing well. We don't suffer from hunger. We're not thirsty or anything like that, and you're here too.´" (01_EL_01)