Care-home Nurses' responses to the COVID-19 pandemic: Managing ethical conundrums at personal cost: A qualitative study

Exposure to distressing situations among registered nurses during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

The COVID-19 pandemic exacerbated distressing situations among healthcare professionals, due to resource limitations and complex patient care challenges.

RESEARCH OBJECTIVES

The research aims to explore the frequency of RNs' exposure to distressing situations across various care settings during the pandemic and assess the association between this exposure and: (1) stress of conscience, (2) intentions to leave the profession, (3) job satisfaction, and (4) self-rated health in the late phase of the pandemic. In addition, the aim was to describe other common situations they encountered during the pandemic.

RESEARCH DESIGN

A cross-sectional multi-method study was conducted with participants recruited from a national cohort of Registered Nurses (RNs) between October 2021 and January 2022. In total, 3,958 individuals met the eligibility criteria, with 2,237 participants (56.5%) responding to the survey. Among these respondents, 1,881 answered questions about distressing situations, and 239 shared open-ended responses about their experiences.

RESULTS

The results showed that during the peak of the COVID-19 pandemic, between 24% and 70% of RNs encountered distressing situations on a weekly basis or more often. Over 70% reported difficulties in communication due to personal protective equipment. Additionally, just over 40% of RNs reported working in situations lacking clear guidelines and facing prioritization challenges. RNs exposed to these distressing situations were frequently nearly twice as likely to experience stress of conscience (44% vs. 21%, [OR] = 2.87) and showed a stronger intention to leave the profession (25% vs. 14%, [OR] = 1.98). Moreover, they reported lower job satisfaction (85% vs. 92%, [OR] = 0.50) and poorer self-rated health (34% vs. 50%, [OR] = 0.52) compared to their counterparts with less exposure. In addition, RNs experienced a lack of support, understaffing, and working beyond their expertise, leading to emotional and physical exhaustion. They felt inadequate due to overwhelming workloads and limited recovery time.

CONCLUSION

The COVID-19 pandemic has significantly impacted RNs, underscoring the need for strong organizational support and leadership. Nurses require guidance from leaders and institutions to manage distress and ethical challenges effectively. Future strategies should prioritize adequate staffing, skill development, teamwork, mental health resources, and transparent communication to support nurses' wellbeing and recovery, ensuring the delivery of high-quality care.

Knowledge, Attitude, and Practice of Chinese Medical Staff for Common Resident Emergencies in Elder Care Facilities: A Structural Equation Model-Based Survey

Aims/Background Increasing population longevity poses challenges to health care for the elderly. Facility-based care is a primary approach to elder care, and medical staff in these settings must be skilled in managing emergencies, as the elderly are more likely to experience emergencies than those living in the community. To aid in developing first aid training, procedures, and regulations for medical staff in elder care facilities, we evaluated the knowledge, attitude, and practice (KAP) levels concerning commonly reported emergencies, as well as the correlations between these factors. Methods The questionnaires were distributed among 1493 doctors and nurses within 258 residential facilities in Shanghai between 1 May 2023 and 31 October 2023. Of the 725 valid questionnaires, we obtained socio-demographic and KAP-related data. Structural equation modeling (SEM) was applied to determine associations between KAP elements. Results Chinese medical staff in elder care facilities had relatively suboptimal knowledge regarding first aid for common resident emergencies, with only 41.7% rated as good. Their levels of attitude and practice were optimistic. The proportion of medical staff demonstrating a positive attitude and appropriate practice in first aid was 79.31% and 68.00%, respectively. Age, gender, educational level, experience with witnessing and dealing with emergencies were identified as factors influencing knowledge, attitude, and practice. Structural equation modeling revealed that attitude and knowledge could directly or indirectly affect management approaches for common elderly emergencies, with a correlation coefficient of 0.11 between knowledge and attitude and 0.66 between attitude and practice. The "first aid for nine preventions" and "cardiac arrest and cardiopulmonary resuscitation" substantially influenced knowledge acquisition, with correlation coefficients of 0.66 and 0.48, respectively. "Attitude toward emergency management" had a significant impact on the attitude of the medical staff, with correlation coefficients of 0.90. Conclusion Knowledge, attitude, and practice are interconnected, with knowledge indirectly influencing behavior by shaping attitude. The medical staff in elder care facilities in Shanghai had a limited understanding of first aid for common resident emergencies. Targeted training and education are urgently required to enhance their knowledge and skills in managing common emergencies among elderly patients, while fostering a strong sense of responsibility. Such initiatives can ensure prompt and appropriate first aid actions, boosting their confidence and promoting a positive and harmonious environment for medical staff and elderly residents.

Barriers and Facilitators to Successful Outbreak Management of Viral Respiratory Tract Infections in Long-Term Care Facilities: A Qualitative Interview Study

OBJECTIVES

Effective management of COVID-19 and influenza outbreaks in nursing homes (NHs) depends on preparation by the NH organization and the rightful execution of infection prevention and control (IPC) measures by NH staff. To be better prepared for future outbreaks and pandemics, we need a better understanding of barriers and facilitators to the execution of measures. This study aims to investigate which barriers and facilitators were perceived by Dutch NH staff during the execution of IPC measures to control outbreaks of COVID-19 and influenza in the COVID-19 pandemic end stage.

DESIGN

Qualitative interview study.

SETTING

Nursing homes where COVID-19 and/or influenza outbreaks (defined as at least 2 confirmed cases on an NH unit) occurred between February 2023 and April 2023.

METHODS

We monitored 24 COVID-19 and influenza outbreaks in 14 Dutch NH organizations in the pandemic end stage. Purposive sampling was used to select a variety of outbreaks for more extensive monitoring, including qualitative interviews with NH staff involved in the management of the outbreak. During the interviews, participants reflected on the management of monitored outbreaks as well as previous outbreaks. Interview transcripts were thematically analyzed to identify determinants of IPC strategy execution.

RESULTS

Determinants of IPC execution were clustered according to themes: motivations and attitudes; appropriateness of measures; guidance and cooperation of NH staff; communication; knowledge and skills; architectural features of the NH location; and availability of resources.

CONCLUSIONS AND IMPLICATIONS

The current study provides in-depth insight into which determinants facilitated and impeded IPC execution during COVID-19 and influenza outbreaks pandemic end stage. These findings may help NHs to better prepare for the management of future outbreaks and pandemics, and provide insights into what determinants to consider for developing IPC strategies.

Visualising the voices of nursing: a co-designed video capturing the lived experiences of nurses in Northern Ireland during the COVID-19 pandemic

BACKGROUND

Nurses were at the forefront of managing the COVID-19 pandemic. In response, the Royal College of Nursing in Northern Ireland commissioned a longitudinal qualitative survey using the Cognitive Edge SenseMaker® tool to capture nurses' experiences of delivering care from April 2020 to March 2021.

AIM

To explore the effect of a co-designed video based on the findings of SenseMaker®, of the lived experience of nurses in Northern Ireland during the 2020/2021 global pandemic.

METHOD

Quotes were selected from the SenseMaker® report of nurses' (n = 676) which conveyed the experiences of nurses during COVID-19. Three co-design workshops were conducted. The first covering the plan for extraction of data from the SenseMaker® report, the second content development and script writing and the third covering feedback and revisions. The video was filmed and edited in the Drama Studies, School of Arts, English and Languages, Queen's University Belfast. The live launch event took place in the Royal College of Nursing conference venue on 8th February 2024. Data to gauge the effect of the video were gathered via audience participation, MS Teams Version 1.7. chat participation, Mentimeter poll and MS forms survey. The link for the video and survey was accessible via the School of Nursing and Midwifery, Queens University Belfast website after the launch event. The findings were analysed using systematic text condensation using NVivo version 1.6. The study was approved by the Faculty of Medicine, Health and Life Sciences research committee at Queen's University Belfast following peer review (REC Reference: MHLS 23_100).

RESULTS

Twenty-eight participants completed the survey; 30 participants attended the live event. Overall, 93% (n = 26) of participants confirmed that the video-based monologues effectively conveyed the emotional perspective and lived experiences of nurses during the COVID-19 pandemic. Four themes emerged - personal reflection and emotional effect, connection and solidarity amidst disappointment, moral injury and resentment, lessons learned and the need for change.

CONCLUSION

Wider dissemination of the co-created video-based narratives, with focus on advocacy to policy makers, is needed to prioritise the emotional well-being of nurses and other professionals. There is potential in using video-based monologies to facilitate positive change and better support for professionals, including nursing students in future crises. Further research is needed to assess the broader effect of such healthcare-related research methodologies.

Concept Analysis: The Occupational Experiences of Long-Term Care Nurses-Navigating Fragmented Transitions

AIM

Transitions are broadly defined as movements from one place, stage, or subject to another. However, transitions which are broken and incomplete are referred to fragmented transitions. The aims of this concept analysis were to analyze the navigation of fragmented occupational transitions among long-term care nurses and to develop a working conceptual definition of fragmented occupational transitions to inform diverse stakeholders.

DESIGN

Concept analysis.

DATA SOURCES

Google Scholar, PubMed, and the Cumulative Index of Nursing and Allied Health Literature databases were accessed. Identified sources were interprofessional scholarly literature published between January 1, 2018, and January 1, 2024, and seminal references.

METHOD

Walker and Avant's eight-stage concept analysis method.

RESULTS

Occupational transitions in long-term care are fragmented leading to grievous challenges across multiple aspects of nurses' lives. An analysis of the literature using a Transitions Theory lens reveals that their thoughts, feelings and ethical decisions are influenced over time by these transitions. Cardinal attributes include: (1) Fragmentation, (2) Ill-timing, (3) Disruption, (4) Liminality, (5) Ambiguity, (6) Ambivalence and (7) Facilitators/Inhibitors. Antecedents stem from external sources and facility-led initiatives. Consequences encompass product and process outcomes. Product outcomes include physical and psychological conditions, and process outcomes encompass resilience, flexibility, connection, coping, creativity, and communication.

CONCLUSION

This concept analysis advances the science for understanding nurses' occupational transitional experiences in long-term care. It will assist in risk assessment and instrument development ultimately improving the quality of long-term care.

IMPLICATIONS

Fragmented occupational transitions in long-term care are multifaceted and complex phenomena that require distinct responses from government, healthcare leaders, and scholars to improve the plight of long-term care nurses and stakeholders.

PATIENT OR PUBLIC CONTRIBUTION

Dr. A. I. Meleis contributed to this article by sharing her vast insight into transitions.

Dying in residential care homes during the early COVID-19 pandemic: a qualitative interview study

BACKGROUND

Early in the COVID-19 pandemic, care homes (long-term care facilities) globally were severely impacted in many ways, including end-of-life care and death of residents. They experienced significantly elevated mortality rates amongst residents, compounded by restrictions on support from external healthcare and specialist palliative care providers. Family access to dying residents was often severely restricted. This paper explores experiences of deaths, dying and end-of-life care in care homes during the first year of the pandemic (Spring 2020-2021).

METHODS

As part of a wider study of experiences in care homes in Northern England during the early pandemic, we conducted semi-structured interviews with care home staff (16), residents (3), family members (5) and health service staff (10). Interviews were analysed using reflexive thematic analysis, this secondary analysis focusing on experiences of death and dying over the period.

RESULTS

Thematic analysis generated three key themes: (1) Preparing for large scale deaths: Care home staff reported a sense of foreboding at requirements to prepare for large scale resident deaths, sometimes feeling left with minimal external support to manage this, and uneasy about the rapid roll-out of emergency care planning to residents; (2) Balancing support and policing visiting during the terminal phase: The requirement to restrict access for family members when their relatives were dying was experienced as distressing for both family members and care home staff; and, (3) Distress surrounding deaths for staff and families: Care home staff were distressed by the frequency and speed of deaths that they witnessed when their care home had a COVID-19 outbreak. Family separation near time of death was a source of distress for everyone involved, with suggestions that this led to regrets in bereavement for family members, and moral distress in staff.

CONCLUSIONS

The experience of death and dying in care homes in the early waves of the COVID-19 pandemic was extremely challenging for care home staff and family members. Our analysis suggests that the ramifications of stringent visitation policies and the consequent distress may shape experiences in bereavement. Monitoring for longer term consequences, such as prolonged grief and moral injury, should be a priority.

How did student district nurses feel during the COVID-19 pandemic? A qualitative study

BACKGROUND

The COVID-19 pandemic placed a huge strain on healthcare services around the world, including community services. Students also faced substantial disturbance to educational programmes. Student district nurses are usually employed members of staff and can be recalled to the workforce, whereas pre-registration students cannot.

AIMS

This paper explores the feelings and experiences of student district nurses during the first UK national lockdown of the COVID-19 pandemic. An interpretative phenomenological approach was taken.

METHOD

A semi structured 1:1 interview and focus group was held via zoom in July 2020. A total of eight student district nurses, who were all registered adult nurses, took part. Data was analysed using the Braun and Clarke model to identify themes.

RESULTS

The findings related to their experience of being a community adult registered nurse on the frontline, while also being a student district nurse. Three themes were identified from the analysis: anxiety and uncertainty, management of risk and teamwork.

CONCLUSION

This study highlights the contribution that community nurses made in the clinical response to the COVID-19 pandemic. It adds to a paucity of literature available from this clinical setting and specifically from the viewpoint of a student district nurse. There is much written on the strains on hospital care, but it should be remembered that district nursing is the service that never shuts its doors because it has reached capacity. This study found that a lack of communication and uncertainty about their future as students contributed to heightened stress and anxiety. Teamwork and camaraderie are a vital aspect of any team and one that can support resilience in times of heightened stress. A lack of face-to-face interaction can lead to team members feeling isolated. Digital technology can be used to reduce this feeling when possible.

Health and care workers in long-term care facilities and their role in preventing emerging infectious diseases: A scoping review

BACKGROUND

The COVID-19 pandemic has had a tremendous impact on healthcare systems worldwide. In particular, long-term care facilities have proved more susceptible to infection as they care for vulnerable populations at high risk of chronic illness. How this impacts the role and core competencies of health and care workers in these facilities remains less understood.

AIM

Describe how health and care workers contribute to the prevention of emerging infectious diseases in long-term care facilities.

DESIGN

A scoping review.

METHODS

A systematic search of literature dating from 2002 to 2022 was conducted in the following databases: EMBASE, Medline (Ovid), Cochrane Library, CINAHL Plus with Full Text (EBSCOhost), Web of Science, and AgeLine. Studies were selected if they focused on health and care workers in long-term care facilities, offered a perspective on the prevention of emerging infectious diseases or infection prevention and control, and were original qualitative or quantitative studies in English. Data were extracted, cross-checked and analyzed by two researchers, and any difference in views regarding the appropriateness of literature would be resolved by consulting a third researcher. An inductive descriptive approach was applied for the analysis of results, and themes were established via consensus meetings.

RESULTS

A total of fourteen studies from Asia, Europe, and the Americas were included. Three themes emerged from the review: "The roles of health and care workers evolve with the times", "The core competencies of health and care workers are essential for preventing emerging infectious diseases in long-term care facilities" and "The key to successful prevention of emerging infectious diseases in long-term care facilities is through a systematic, comprehensive effort that mobilize health and care workers at all levels". Health and care workers had to take on increasingly complex roles and rely on their core competencies to cope with epidemic changes, and facility resources, employee quality and management models were found to have significantly improved infection prevention and control outcomes.

CONCLUSIONS

The roles of health and care workers are evolving, and effective infection prevention within long-term care facilities depends on their ability to perform core competencies with skill and confidence. Moreover, a systematic, comprehensive framework, for which this paper proposes three guidelines, is urgently needed to ensure consistent policy implementation within the facility as well as support and access to resources for health and care workers.

CLINICAL RELEVANCE

Infection prevention efforts within long-term care facilities must take into account the evolving roles of health and care workers, with a focus on guaranteeing access to resources, training and support that will help them gain the core competencies necessary for juggling those roles. In addition, there is an urgent need for research instruments that will help assess those competencies and identify areas of improvement.

U.S. nursing home leadership experiences with COVID-19 and its impact on residents and staff: A qualitative analysis

OBJECTIVES

To explore experiences of U.S. (United States) nursing home leadership during the COVID-19 pandemic in their efforts to address resident loneliness and social isolation and to elicit stories about personal and professional impacts on themselves and staff.

DESIGN

Qualitative inquiry via three optional open-ended questions appended to a national self-administered survey of American nursing home leaders was employed. Textual data was analyzed using an iterative reflexive thematic approach.

SETTING AND PARTICIPANTS

A stratified sample frame defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5) was employed. Web survey links and paper surveys were sent to 1,676 nursing home directors of nursing between February and May 2022.

RESULTS

Open text responses were collected from 271 nursing homes. Broad themes included: 1) Addressing needs of residents & families; 2) Challenges; and 3) Personal experiences of nursing home leadership/staff. Respondents described trauma to residents, staff, and leadership. Resident loneliness was addressed using existing and newer technologies and innovative indoor and outdoor activities. Residents experienced fear, illness, loss, and sometimes death. Isolation from family and lack of touch were particularly difficult. Regulations were seen as punitive while ignoring emotional needs of residents. Staffing challenges and pressures to do more with less created additional stress. Leadership and staff made significant sacrifices resulting in physical, social, and emotional consequences. Beneficial outcomes included staff bonding, professional growth, and permanent implementation of new interventions.

CONCLUSIONS AND IMPLICATIONS

New and creative interventions were successfully implemented to address social isolation and loneliness. Improved Wi-Fi and other nursing home infrastructure upgrades are needed to maintain them. Reimagining often conflicting overlapping federal, state, and local regulations, grounding them in good clinical judgement, and incentivizing performance improvement should be considered. Trauma experienced by staff needs to be addressed to deal with current and future workforce needs.

Listening and learning: a qualitative study of Scottish care home staff experiences of managing COVID-19 between March 2020-August 2022

BACKGROUND

The serious outcomes of outbreaks of COVID-19 in care homes have been described internationally. The experiences of professionals working through outbreaks has received less attention, missing opportunities to acknowledge and learn lessons. Our aim was to explore the experiences of care home staff in Scotland of managing COVID-19 within their homes to help inform understanding and future practice.

METHODS

From April to August 2022, 34 individual semi-structured interviews were conducted with care home staff working in homes which experienced an outbreak(s) of COVID-19. Reflexive thematic methods were used to analyse verbatim deidentified transcripts.

FINDINGS

There was no singular experience of COVID-19 outbreaks within care homes. We identified four broad groupings of homes with outbreaks (significant outbreaks, managed outbreaks, outbreaks in remote/rural homes & outbreaks in homes supporting younger adults), with overlaps in timing and severity and variation in the support received and impact. The national response to the COVID-19 pandemic resulted in fundamental change to care home relationships. Staff responded by adaptation in uncertainty. However, they were challenged by emerging inequalities influencing residents' care. There were tensions between staff experience and evolving external approaches to regulation and oversight. All this change resulted in psychological impacts on staff. However, there was also widespread evidence of compassionate leadership and teamwork in their responses. Effective sources of support were underpinned by respectful relationships and continuity, tailored to individual contexts.

CONCLUSIONS

The lived experiences of care home staff during the COVID-19 pandemic provide valuable insights applicable beyond the pandemic context. This includes: recognition of the specialism, complexity and diversity of care home practice; the value afforded by embedding genuine representation and involvement in planning, policy-making and research; the need for individualising to people in their contexts and the value of fostering respectful relationships across professional groups to support residents.