Psychosocial burden in nurses working in nursing homes during the Covid-19 pandemic: a cross-sectional study with quantitative and qualitative data

Eligible for participation were geriatric nurses and nursing assistants working in long-term care facilities in rural and urban regions of Brandenburg state. To ensure a defined study area, we identified four regions with particular urban or rural characteristics, in which we contacted all nursing home facilities. To identify all nursing homes within the target regions, we conducted a comprehensive search, using an open-access register [18] and an additional database created by the Institute of Social Medicine and Epidemiology (MHB). The management of these facilities were approached by study staff for participation (e-mail and telephone). Overall, 37 out of 58 facilities agreed to take part (rural region 1: 8/13; rural region 2: 9/17; urban region 1: 13/18; urban region 2: 7/10). Between August and October 2020 (i.e. within the interim period between the first two waves and at the beginning of the second wave of the Covid-19 pandemic in Germany) study materials containing study information and the anonymous questionnaire were sent to the participating facilities and distributed to all nurses and nursing assistants working on long-term care wards. Questionnaires were returned individually by mail using enclosed pre-paid envelopes.

When approached for completion of the survey, potential study participants also received a written invitation to participate in a telephonic, semi-structured qualitative interview aiming at exploring in more depth the dynamics and lived realities of working in long-term geriatric care during the pandemic. This recruitment strategy failed to generate study participants leading to a changed sampling through the professional networks of the authors. Sample criteria were broadened such that care home nurses from all regions of Brandenburg were eligible to participate. Interviews were conducted in June 2021 (during the interim period between the third and fourth wave of the pandemic in Germany).

Interviewees spoke about both the physical and the broader psychosocial implications of working under the hygiene protocols adopted in the nursing home. Staff shortages led to longer working hours, the need to maintain distance to colleagues meant long queues at the changing room or the prohibition of taking joint breaks. In particular, interviewees reported of added pressure due to the mandatory wearing of personal protective equipment (PPE, i.e. masks, visors, hazmat suits, gloves, caps and overshoes). Beyond the mere physical implications, changing into and out of PPE often several times a day significantly impeded everyday care routines, particularly during active outbreaks where spatial segregation of infected and non-infected residents was impossible. In contrast, time with residents and performing actual care work such as preventing social and emotional deprivation through social interaction and conversation was limited, making interviewees feel as if they let residents ‘fall through the cracks’ (CP01):

Well, preventing residents’ social isolation was impossible. You didn’t even have the time to really engage with residents, because due to the fact that we had to change [into PPE] completely anew for each resident, we lost a lot of time (CP06).

Interviewees working in managerial positions also reported that adhering to, implementing and monitoring regulations that sometimes changed day-by-day increased pressure on them and fundamentally changed their daily routines.

Most interviewees expressed deep concern for residents being isolated for long periods. Due to restrictions on group activities, shared meals and visitors, residents were largely confined to their rooms, especially during active Covid-19 outbreaks on their ward. Interviewees often witnessed grave deteriorations in residents’ physiological and mental health during this time, and told us of their concern for their well-being. Having to isolate residents contrasted their understanding of the social conditions of health and well-being, and contradicted the significance of direct, often sensory, interaction with a range of interlocutors (staff, relatives, other residents, nursing aides). Many interviewees worried about this not only from a nursing science standpoint, but also from a deeply human, emotional perspective:

Well in sum, one could also observe, residents who were full of life before, who had visitors at least twice a week, they completely collapsed, they almost died on us. They withdrew, they deteriorated cognitively, and often very much so. How I feel about this? Well, pretty negative (CP01).

This was especially difficult when interacting with cognitively compromised residents who often did not understand the necessity of the regulations, and were even more vulnerable to the effects of isolation.

Interviewees reported increased stress due to the ban on relatives visiting residents, in place across most are homes in the beginning (March–May 2020) and during the third wave (December 2020–March 2021) of the pandemic. While visitors usually support and unburden care staff through time spent with individual residents, this support suddenly ceased to exist. Worse, relatives often became an additional burden for interviewees. Relatives needed to be kept informed about the condition of residents, and interviewees provided emotional support for relatives when the resident’s status deteriorated. Some found it especially stressful to inform relatives about residents’ immediate death. Moreover, some relatives were unaccepting of the regulations and blamed interviewees for barring them from visiting. In many instances, interviewees reported of insults and abuse from relatives, which they had to mediate or fend off. After restrictions on visits had eased and when palliative visits were granted, geriatric nurses were responsible for ensuring that residents as well as visitors adhered to the regulations. In many cases, interviewees had to test visitors for Covid-19 at the care home, adding to their workload:

In that moment, where relatives aren’t coming anymore, we are the main contact person for the residents, for their worries, their problems. We are then also responsible for helping shape their leisure time. Those are things that we didn’t really do earlier, because relatives would support us with this (CP14).

However, some interviewees reported feeling more appreciated by relatives and that the shared suffering during the pandemic had strengthened the bond between residents, relatives and staff.

Interviewees found it difficult to provide adequate terminal care for residents. Many reported that they found it extremely difficult to know that residents had to die in isolation, and that they had missed the opportunity to say goodbye to long-term residents with whom they had built strong personal relationships. This tarnished their self-understanding of the kind of palliative care they deemed necessary. Moreover, working conditions, as well as financial pressure to re-fill beds, made it impossible for interviewees to adequately mourn deceased residents. While they admitted that death and dying are natural elements of working in long-term geriatric care, both the quality and quantity of death(s) under Covid-19 were difficult to process. Though tensions had eased at the time of the interview, many realized only then that they had not fully processed residents’ death. Some had been offered supervision or counselling by their supervisors, but most preferred casual conversations with colleagues to make sense of the events.

The residents who were infected with Covid and then also died from it, we could not do them justice anymore. Terminal care or not leaving them alone in those moments, we could not do justice to this. They often laid alone in their rooms. Some older residents still had relatives visiting, for the acute, terminal phase. But many had no one, and this really did something to us (CP07).

While some interviewees were anxious about contracting the virus or had already recovered from Covid-19 at the time of the interview, some were more concerned about infecting relatives or residents at the care home. This was especially worrisome for those who cared for vulnerable family members at home; where possible, interviewees maintained physical distance to those family members. For most, the risk of infection and transmission and the guilt attached to it was a constant companion during their work. Even after infections had eased and most residents and staff members were vaccinated, some interviewees told of the recurring anxiety every time they were tested, and the stigma attached to being ‘the one who brought the virus into the care home’.

Sometimes it really does put you under a lot of pressure. To always be exposed to this situation, to think ‘oh hopefully, I don’t have anything. Oh God, oh God, I hope I’m not the one introducing it [to the care home]. That really does something to you (CP12).

All interviewees reported that the regulations had a negative impact on their ability to provide adequate emotional or psychosocial care, though some noted that the provision of basic care such as personal hygiene was successfully maintained. Conversations, group activities and interpersonal interaction all fell prey to the increased time spent on adhering to the regulations, changing into and out of PPE, testing visitors and staff and interacting with public health institutions. Adherence to hygiene protocols often meant that residents could no longer exercise autonomy, for example about when to get up in the morning or when to take meals. In direct interaction with residents, masks, PPE and restrictions on physical contact significantly limited meaningful interaction. Many interviewees thus experienced an overdetermination of the technical/practical dimensions over the emotional dimensions of care, described as an act of de-individualisation and de-humanisation:

This not-being-able-to-be-there was extremely burdensome to me … This, just to know that they’re sitting in their rooms alone. Over months, they didn’t have anyone, we’re talking about months here. And every day the same, out of bed, get washed, eat at the table, clear the table. This was so unloving, so inhumane! (CP07)

These tensions were amplified when caring for residents with decreased cognitive capacities who did not comprehend the necessity of the regulations and seldom adhered to them, frequently leaving their rooms to mingle with others. Moreover, cognitively impaired patients are even more dependent on stable relationships, mimics and physical touch, all hampered by staff shortages, the use of temporary staff and the mandatory wearing of full PPE. Interviewees observed how these patients suffered from the lack of personal interaction and intimacy, either silently through weight loss or by becoming physically and verbally aggressive but could do relatively little to help, causing great stress for both resident and staff. Some interviewees admitted that they sometimes transgressed the regulations by taking their masks off to allow more ‘human’ interaction, or by taking extra time with residents in need as the situation became unbearable.

When queried about positive effects of the pandemic, however, respondents particularly emphasized enhanced solidarity and community cohesion among the team. While early in the pandemic, some noticed an increasing level of suspicion amongst workers, others reported increased cohesion and a do-it-yourself-mentality due to the lack of governmental support. As soon as infections hit, all respondents observed an elevated team spirit and increased mutual support, including enhanced solidarity with those suffering from long-term effects of a Covid-19 infection. Respondents in managerial positions were worried about attrition or absenteeism but observed the opposite as staff members showed high levels of commitment to residents and colleagues.

A really positive development and very touching was that we, as an institution and also as a team, became a lot closer due to this challenge, and showed a lot more understanding for each other. A new kind of appreciation has developed, this is very, very, positive (CP13).

Our study provides insight into the situation of nurses working in nursing homes in Germany, a population that is still rarely studied despite their supposed disposition for heightened work-related strain during the Covid-19 pandemic. The COPSOQ provided insight into a wider range of work-related stressors and their effects on psychosocial burdens. Furthermore, the application of a frequently used, validated instrument like the COPSOQ facilitates comparison with results from other populations or countries. Moreover, we conducted semi-structured interviews with a specific focus on geriatric nurses’ concrete experiences, which allowed for a deeper understanding of the psychosocial strains directly related to the pandemic.

Nevertheless, there are some limitations to consider. First, we did not have pre-pandemic COPSOQ data of our sample, hindering a direct within-subjects comparison and evaluation of the genuine effect the pandemic had on work-related psychosocial strain within our sample. We solved the problem the best possible way by contrasting our results against a large German reference group with identical occupational backgrounds evaluated in the years before the pandemic. Nevertheless, we cannot fully exclude possible pre-existing differences between the two samples. However, most of the identified differences between our sample and the reference group were supported by results gained within the qualitative arm of this study and external findings, strengthening the assumption that the found discrepancies are genuine effects due to the pandemic. Second, despite wide distribution of the questionnaire, we reached a comparatively small sample size, which might have led to selection bias. Especially highly burdened nurses may not have participated, which in turn could have resulted in an underestimation of the impact the crisis had on the target group. Considering the high number of stressors we identified, this assumption makes the need for support and de-escalation in care even more urgent. Third, the COPSOQ was administered at a time when study participants may not yet have had personal outbreak experiences at work. Due to data protection we cannot link the survey data to the nursing homes. For this reason, we do not know in what ways the experience of actual outbreaks would influence the study results. Fourth, we were not able to recruit a subsample of interviewees from our original quantitative sample. Nevertheless, our interviewees were nurses working in nursing homes within the state of Brandenburg, comparable in age and interviewed during the Covid-19 pandemic. Thus, they most likely had similar work-related experiences, although most of the interviewees, except for three, experienced outbreaks at work.