Experiences of Healthcare Workers in Long-Term Care during COVID-19: A Scoping Review

Using experience-based co-design approach to address mental health issues among healthcare workers and leaders in long-term care

Introduction

Burnout remains a critical issue within the long-term care (LTC) sector, underscoring the urgent need for early detection and prevention strategies targeting the healthcare workforce. This paper aimed to describe the processes of uncovering the underlying drivers of burnout and distress among LTC workers, providing a foundational understanding to inform the development of a Burnout Assessment Tool (BAT).

Materials and methods

Using an experience-based co-design approach, 11 focus groups were held with a purposive sample of 24 Ontario LTC workers between July 2023 and October 2024. Each session, lasting 2 h, included 4-5 participants representing a diverse range of professional and occupational roles, including personal support workers, nurses, social workers, and administrators or leaders. The objectives of this approach were two-fold: (1) to explore the work-related experiences of LTC workers; and (2) to examine their perceptions of existing burnout and distress tools, including the Maslach Burnout Inventory-Human Services Survey, to assess their relevance and applicability within the LTC context. Each focus group session was audio-recorded and transcribed verbatim. An iterative process generated codes from the transcripts that culminated in a thematic framework of key findings.

Results

Four interrelated themes emerged: (1) challenges inherent in the LTC work environment; (2) the impacts of workplace pressures on employee health and well-being; (3) managing psychosocial risk factors in the workplace; and (4) the need for a context-specific tool to assess burnout in LTC settings. Participants provided in-depth perspectives on their roles within the LTC sector, highlighting the profound impact of burnout on their well-being and the persistent challenges they face in their work environment.

Discussion/conclusion

The findings highlight the pressing need for tailored systemic interventions to effectively address burnout and moral distress among LTC workers and leaders. By employing a co-design approach, this study offers critical insights into the lived experiences of these workers, informing the development and refinement of burnout assessment tools to better reflect the unique needs of this workforce. Developing a BAT, co-created by and for LTC workers, coupled with robust support systems, is crucial to addressing the rising distress and fostering resilience within this vital sector.

Navigating Workforce Challenges in Long-Term Care: A Co-Design Approach to Solutions

(1) Background: The enduring impact of COVID-19 on the long-term care (LTC) sector remains uncertain, necessitating targeted efforts to address current and emerging challenges. This study aims to identify the key stressors faced by healthcare workers (HCWs) in LTC and to co-develop innovative, actionable strategies that mitigate these stressors, foster resilience, and promote workforce retention. (2) Methods: This study utilized a qualitative co-design methodology within a mixed-methods, multi-phase framework conducted between July 2023 and October 2024. This article focuses on Phase 1, which involved 11 semi-structured focus groups and steering group discussions with 24 HCWs, including personal support workers (PSWs), nurses, and LTC administrators across Ontario to explore workplace-related distress and foster a shared understanding of challenges in the LTC sector. Data were audio-recorded, transcribed verbatim, and analyzed using thematic analysis to derive key themes and actionable insights. (3) Results: Key themes emerging from co-design sessions included the need for (i) effective workload management tools, (ii) the prioritization of psychological safety and mental health services, (iii) reducing regulatory and bureaucratic burdens, (iv) strengthening management practices, and (v) fostering recognition and a positive sector image. Co-design sessions with HCWs and leaders facilitated the identification of priority issues and high-level solutions, including addressing workload issues, implementing mental health and support programs, enhancing work-life integration, improving management training, and promoting psychological safety in LTC settings. (4) Conclusions: This study deepens our understanding of workplace challenges in the LTC sector and the factors contributing to HCWs' mental distress. Leveraging a co-design approach offers valuable insights into the lived experiences of HCWs and leaders. The findings provide actionable guidance for LTC leaders and policymakers to create effective, tailored interventions that actively engage HCWs in addressing workplace stressors and mitigating recurrent challenges.

Supporting Family Caregivers of Nursing Home Residents with Dementia in Their Last Week of Life: A Survey Among Bereaved Family Caregivers

Background

Family caregivers of people with dementia in nursing homes may need support from healthcare providers, especially when death is approaching.

Objective

To increase our understanding of family caregivers' experiences in their relative's last week of life before and during the pandemic, their needs for emotional, practical, and spiritual support, and the extent to which those needs are accommodated by healthcare providers.

Design

Survey among bereaved family caregivers of people with dementia recruited from six nursing homes in the Netherlands in 2018-2019 and 2020-2022.

Results

The questionnaire was completed by 165 family caregivers (response rate: 55%). Most respondents (79%) rated the overall care they received as "excellent," "very good," or "good." More respondents reported a need for emotional (74%) and practical (64%) support than for spiritual support (37%). Emotional and practical support were more commonly "always" or "most of the time" provided (63% and 51%, respectively) than spiritual support (22%). Differences existed in the presence of practical, emotional, and spiritual support needs (p < 0.001) and the frequency in which those support types were provided when there was a need (p < 0.001). The overall care that was received was more likely to be rated as "excellent" or "very good" when a higher frequency of emotional (p < 0.001), spiritual (p < 0.002), or practical (p < 0.001) support was reported. Before and during the pandemic, family caregivers' responses were mostly similar.

Conclusion

Family caregivers had support needs that were not always met, which was especially the case for spiritual support needs. Healthcare providers should be trained to accommodate support needs and refer to appropriate support services when necessary.

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.

Unveiling the impact: understanding long-term care workers' experiences and their perceptions of resident challenges amidst the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, long-term care (LTC) facilities in Canada were confronted with many rapidly changing public health safety guidelines. Based on the guidelines, LTC facilities had to implement a series of virus containment and mitigation measures, presenting significant challenges for both workers and residents. This research aims to provide insights that could be used to guide improvements in the experiences of LTC workers, and of residents, in future pandemic crises.

METHODS

A qualitative multi-case study was used to explore the pandemic experiences of a demographically diverse group of LTC workers in Canada, focusing on how public health safety guidelines impacted them, and their perceptions of challenges faced by residents. Fourteen workers were engaged from facilities in Nova Scotia and British Columbia, which are regions distinct geographically and with differences in safety guidelines and implementation. Semi-structured interviews were conducted between April to October 2021. Using thematic analysis, we identified patterns within and across the interview transcripts.

RESULTS

The thematic analysis provided an understanding of the experiences and perspectives of LTC workers. There were four key themes: (1) Tangling with Uncertainty, that describes the effects of ambiguous messaging and shifting COVID-19 safety guidance on workers; (2) Finding Voice, that highlights how workers coped with feelings of helplessness during the healthcare crisis; (3) Ripple Effects, of pandemic pressures on workers beyond resident care, that included strengthening of inter-colleague support as well as financial challenges, and; (4) Loss of Home, where workers perceived that protection of residents led to a loss of the residents' home environment, personal freedom, and autonomy.

CONCLUSIONS

The findings suggest that LTC workers' experiences during future pandemics may be improved by their inclusion in the development of public health safety guidelines, facilitating inter-colleague support systems, and ensuring worker financial stability. A balance should be found between preventing infection in LTC facilities and retaining the principles of holistic and resident-centered care for workers' and residents' mental health benefits.

"Four I" Framework for Telehealth Optimization in Congregate Care Communities

Background: Telehealth can provide innovative models of care for people living in congregate care communities (CCC), but lack of consistent workflow is a barrier for administrators and staff. We propose a framework for CCC to implement workflows for age-inclusive telehealth. Methods: As part of an infection control initiative with a focus on telehealth optimization, Virginia Infection Mitigation, Prevention and Control Through Technology developed relationships with administrators and staff of CCC across the Commonwealth of Virginia. Partners in this community of practice completed a statewide survey that we conducted on anticipated and experienced barriers to telehealth implementation. Through survey responses, virtual meetings with organizational leadership, and on-site facility visits, our team assessed the strengths, needs, and goals for telehealth capability. Working with administrative and clinical teams, we developed a consultation report to define short- and long-term implementation steps. Results: We collaborated with a nonprofit organization supporting a community of people with neurodevelopmental disabilities and a rural Program of All-Inclusive Care for the Elderly. We developed a framework for telehealth optimization with four tiers: Initiate, Integrate, Incentivize, and Inspire. Each stage included an overall goal with corresponding interventions to guide program implementation. Discussion: The "Four I" Framework can be used to outline telehealth readiness and implement workflows for CCC. We aim to further develop an iterative process and to collaborate with additional organizations to optimize telehealth programs.

Cost-effectiveness-analysis of oral health remotivation and reinstruction in nursing homes in a cluster-randomized controlled trial

OBJECTIVES

We conducted a cluster-randomized-controlled trial (cRCT) in 18 German nursing homes (NH) to evaluate the cost-effectiveness of reinstruction and remotivation of nursing staff by dental assistants (DAs) over 13 months.

METHODS

In the intervention arm, dentists examined NH residents, identified oral health conditions, and prescribed individualized oral care interventions. Nursing staff delivered these interventions, with regular follow-up support from DAs (reinstruction and remotivation). In the control group, similar interventions were prescribed via a standardized form, without reinstruction and remotivation (standard of care). The primary outcome was Oral-Health-related Quality-of-Life (OHrQoL) using the Geriatric/General Oral Health Assessment Index (ADD-GOHAI). Secondary outcomes included Health-related Quality-of-Life (HrQoL) using the EQ-5D summary index and caries experience (DMFT index). Costs, including those for staff, materials, and travel, were assessed in Euro 2022. Cost-effectiveness ratios and bootstrapping simulations assessed cost-effectiveness-acceptability at different willingness-to-pay thresholds.

RESULTS

Of 358 recruited participants, 68 and 63 in the intervention and control group completed the study. No significant differences existed between groups in demographics or baseline health measures. After 13 months, changes in ADD-GOHAI and DMFT scores were minimal and non-significant, while EQ-5D scores decreased in the intervention group (p < 0.001). Total costs were higher in the intervention arm (median 121.10 Euro) versus the control (median 0 Euro, p < 0.001), mainly due to travel expenses. The intervention increased dental service use but demonstrated lower cost-effectiveness acceptability.

CONCLUSIONS

DA-led reinstruction did not improve OHrQoL, negatively impacted HrQoL, and increased costs. Notably, our study was suffering from significant attrition, impacting on statistical power.

CLINICAL SIGNIFICANCE

Reinstruction and remotivation by dental assistants did not improve OHrQoL, but generated significant costs, mainly due to an uptake of dental services.

TRIAL REGISTRATION

ClinicalTrials.gov (Trial registration number NCT04140929).

"Definitely a Dark Time:" professional and ethical issues in post-acute care physical therapy during the COVID-19 pandemic

BACKGROUND

Disproportionate effects of the SARS-CoV-2 (COVID-19) pandemic on older adults in post-acute care settings created many professional and ethical challenges for patients and healthcare providers.

OBJECTIVE

The purpose of this study was to examine the professional and ethical issues of physical therapists (PTs) and physical therapist assistants (PTAs) in providing facility-based post-acute care in residential settings (skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals) during the COVID-19 pandemic.

METHODS

A qualitative descriptive research design was used to explore professional and ethical issues during the COVID-19 pandemic. PTs and PTAs described their experiences during semi-structured interviews conducted virtually. Interview data was analyzed with reflexive thematic analysis.

RESULTS

Thematic analysis produced 4 themes: facility-wide battle against infection and death, doing the best you can to provide care amidst COVID-19 constraints, promoting ethical good and doing the right thing, and a dark intense time.

CONCLUSIONS

Professional and ethical constraints on providing care faced by PTs and PTAs during the COVID-19 pandemic can inform current and future clinical practice. Although some of the challenges faced by PTs and PTAs were unique to COVID-19, many problems represent preexisting systemic and organizational issues that were exacerbated by the pandemic.

Perceptions of Resilience Among Nurses: A Qualitative Study Based on the Society-To-Cells Framework

AIM(S)

To explore the perceptions of resilience among nurses using the Society-to-Cells Resilience Theory and examine how multilevel factors influence their ability to maintain resilience in high-stress environments.

DESIGN

A qualitative study using semi-structured interviews.

METHODS

Sixteen registered nurses from various healthcare settings in the Asir region, Saudi Arabia, participated in face-to-face interviews conducted from February to April 2024. The interviews were analysed thematically to identify key factors affecting resilience at individual, familial, institutional and societal levels.

RESULTS

Four key themes emerged: individual coping strategies, family and social support, institutional support mechanisms and societal recognition. Nurses identified personal coping methods, such as mindfulness and exercise, as essential for maintaining resilience. Family and social networks played a crucial role in emotional support. Institutional factors, such as adequate staffing and leadership support, were vital to resilience, while a lack of societal recognition negatively impacted nurses' well-being.

CONCLUSION

Resilience in nursing is a multifaceted process influenced by individual, institutional and societal factors. Supportive work environments, adequate resources and recognition of nurses' contributions are critical in fostering resilience.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The findings emphasise the need for healthcare institutions to implement policies and support mechanisms that address both the personal and professional challenges nurses face. Promoting resilience can improve nurse retention, job satisfaction and patient care outcomes.

REPORTING METHOD

This study adhered to the Standards for Reporting Qualitative Research (SRQR) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Behind the Frontlines: Insights for Supporting Mental Health and Staff Retention in the Long-Term Care Workforce

Background/Objectives: Canada's long-term care (LTC) sector is struggling with a significant staffing crisis related to shortages, high-turnover rate, and challenging working conditions. The COVID-19 pandemic exacerbated these issues and emphasized the need for improved mental health support for LTC staff. Understanding and addressing the wellbeing of staff is important for ensuring quality of care and promoting a positive work environment for a healthy workforce. This study explored staff experiences in Canadian LTC homes during the COVID-19 pandemic and offers staff-driven recommendations to support staff mental health and retention moving forward. Methods: We applied the Collaborative Action Research (CAR) methodology to explore practical strategies with LTC staff to inform actions for change. Sixteen staff members working in two large urban Canadian LTC homes were interviewed using remote videoconferencing and phone calls to conduct one-on-one interviews. Thematic analysis was performed. Results: Our analysis identified four themes: depletion, lack of support, providing resources and sense of community. The SUPPORT framework was created based on staff recommendations to improve LTC staff mental health and retention. Conclusions: Urgent attention is needed to support the LTC workforce through practice change and improved policy. The implementation of comprehensive frameworks such as SUPPORT can play a pivotal role in fostering staff resilience, enhancing job satisfaction, and promoting a healthy workforce for aged care.

Nurses' experiences in transitioning to work in the long-term care and home and community care sectors: A phenomenological exploration

BACKGROUND

Nurses in long-term care (LTC) and home and community care (HCC) are well acquainted with the high workloads and manifold job stressors that pervade these sectors, making it increasingly difficult to employ and retain a strong workforce. In response, nursing bridging education programs have been proposed to enhance recruitment and retention. While the efficacy of such programs is supported, the transition to practice experience of new nurse graduates is often associated with feelings of under-preparedness. Understanding the lived experience of nurses transitioning into new roles in LTC and HCC after completing a bridging program may highlight areas of emphasis for future retention efforts.

METHODS

Hermeneutic phenomenology was employed to explore the experiences of new graduate Registered Practical Nurses (RPNs) and Registered Nurses (RNs) from a tuition reimbursement program supporting students enrolled in nursing bridging education from Personal Support Worker (PSW) to RPN/RN and/or RPN to RN in Ontario as they transitioned to practice within LTC and HCC. A series of in-depth semi-structured virtual interviews and iterative analysis explored the meaning of everyday experiences for nurse participants.

RESULTS

From twenty individual interviews (12 initial, 8 follow-up), the experience was embedded in a sense of fulfillment, further considered through four themes - benevolence; growth, eagerness, and anticipation to learn; building from within; and work-life balance.

DISCUSSION

This is the first phenomenological study to report on the meaning of the experience of transitioning to practice for new graduate nurses from bridging education programs as they (re)enter the workforce in LTC and HCC, offering rich insight into their experiences when moving into new roles.

CONCLUSIONS

By illuminating the nuances of this experience, the findings may encourage healthcare leaders to develop helpful policies, strategies, and workplace cultures in LTC and HCC that might better promote the recruitment and retention of nurses in these sectors.

Adoption of assistive technologies in long-term care homes: What the pandemic has taught us

COVID-19 increased the use of technology in everyday life and highlighted critical applications for assistive technologies. This comparative research study explores how assistive technologies, including socially assistive robots, can be adopted by long-term care homes to mitigate the lasting effects of the pandemic. In particular, we investigated the types of assistive technologies used by long-term care facilities to help with the care of older residents and for what tasks. Furthermore, we identified barriers to adoption and proposed policy measures that encourage technology adoption.

SARS-CoV-2 outbreak management in nursing homes in Ireland: reflections of COVID-19 response teams from earlier to later waves of the pandemic

BACKGROUND

A review of key learnings from the response to the COVID-19 pandemic in nursing homes in Ireland can inform planning for future pandemics. This study describes barriers and facilitators contributing to COVID-19 outbreak management from the perspective of frontline teams.

METHODS

A qualitative study involving ten online focus group meetings was conducted. Data was collected between April and June 2023. The focus group discussions explored the views, perceptions and experiences of COVID-19 Response Team (CRT) members, clinical/public health experts who worked with them, and care professionals who worked in frontline managerial roles during the pandemic. All nine Community Healthcare Organisations and six Public Health Areas in Ireland were represented. Inductive reflexive thematic analysis was carried out using NVivo Pro 20.

RESULTS

In total, 54 staff members participated in focus group meetings. Five themes were developed from a thematic analysis that covered topics related to (1) infection prevention and control challenges and response to the pandemic, (2) social model of care and the built environment of nursing homes, (3) nursing home staffing, (4) leadership and staff practices, and (5) support and guidance received during the pandemic.

CONCLUSIONS

The response to the COVID-19 pandemic has resulted in a steep learning curve, internationally and in Ireland. Preparing better for future pandemics not only requires changes to infection control and outbreak response but also to the organisation and operation of nursing homes. There is a great need to strengthen the long-term care sector's regulations and support around staffing levels, nursing home facilities, governance, use of technology, infection prevention and control, contingency planning, and maintaining collaborative relationships and strategic leadership. Key findings and recommendations from the Irish example can be used to improve the quality of care and service delivery at local, national, and policy levels and improve preparedness for future pandemics, in Ireland and internationally.

Past the tipping point: Understanding and addressing burnout among nursing students

Burnout is a widespread concern in healthcare, with nurses bearing a disproportionate burden among healthcare professionals. This epidemic of occupational stress has also affected nursing students, who face the external demands inherent in the profession. In this call-to-action paper, we conducted an extensive literature review exploring strategies aimed at mitigating burnout among nursing students, and offer recommendations for academic institutions, healthcare leaders, research funders, and political leaders, including both the civil service and elected leaders to support the advancement and sustainability of the nursing profession and its workforce.

"COVID-19 - A Perfect Storm": A Qualitative Exploration of Residential Care Facility Managers Perspectives on the Psychosocial Impacts of COVID-19

Growing evidence highlights the negative impact of managing the COVID-19 pandemic on the wellbeing of the healthcare workforce, including in the aged care sector. We undertook a qualitative study during the pandemic's third year to explore the psychosocial impacts on nine managers of residential care facilities (RCFs) across metropolitan and rural New South Wales, the largest state in Australia. Four themes were identified: (1) Increased pressure on maintaining aged care services, (2) Increased responsibility on RCF managers, (3) Psychosocial impacts due to accumulating pressures, and (4) Experience of beneficial supports. COVID-19 compounded pre-pandemic sector challenges and added new stressors. While resilient and resourceful, RCF managers experienced workplace stress and burnout, which may affect quality of resident care and impact on staff retention. There is a need for more investment to effectively support staff, and research to identify optimal psychosocial and management supports.

Ongoing and emerging issues for residential long-term care in the context of Covid-19

Background: Long-term care facilities have been confronted with various workforce challenges, including a poor image within the nursing profession, a shortage of staff, and a growing demand for long-term care. Furthermore, these facilities have been significantly impacted by the pandemic and the respective measures with detrimental effects on residents, staff, and their family members. Aim: This study explored issues in working in residential long-term care from the perspective of nurses and their perception on amplifying and additional effects of Covid-19. Methods: It applied a qualitative design focusing on experiences and views of 25 LTC nurses working in Austrian long term care facilities during the pandemic. Data were collected by conducting in-depth interviews either virtually or in presence. The data analysis was conducted by applying a thematic analysis. Results: The four identified themes are: (1) Work motivation, (2) Dealing with vulnerability, (3) Human Resource Planning and (4) External view on long-term care. For each theme it was delineated which aspects have been present in the pre-Covid-19 situation and which became more visible or arose additionally. Conclusions: Nurturing connection between LTC nurses and with residents and relatives as well as signaling the positive aspects of LTC such as relationships, challenge and responsibility may allow to tackle Human Resource Planning issues.

Adoption of Artificial Intelligence-Enabled Robots in Long-Term Care Homes by Health Care Providers: Scoping Review

BACKGROUND

Long-term care (LTC) homes face the challenges of increasing care needs of residents and a shortage of health care providers. Literature suggests that artificial intelligence (AI)-enabled robots may solve such challenges and support person-centered care. There is a dearth of literature exploring the perspectives of health care providers, which are crucial to implementing AI-enabled robots.

OBJECTIVE

This scoping review aims to explore this scant body of literature to answer two questions: (1) what barriers do health care providers perceive in adopting AI-enabled robots in LTC homes? (2) What strategies can be taken to overcome these barriers to the adoption of AI-enabled robots in LTC homes?

METHODS

We are a team consisting of 3 researchers, 2 health care providers, 2 research trainees, and 1 older adult partner with diverse disciplines in nursing, social work, engineering, and medicine. Referring to the Joanna Briggs Institute methodology, our team searched databases (CINAHL, MEDLINE, PsycINFO, Web of Science, ProQuest, and Google Scholar) for peer-reviewed and gray literature, screened the literature, and extracted the data. We analyzed the data as a team. We compared our findings with the Person-Centered Practice Framework and Consolidated Framework for Implementation Research to further our understanding of the findings.

RESULTS

This review includes 33 articles that met the inclusion criteria. We identified three barriers to AI-enabled robot adoption: (1) perceived technical complexity and limitation; (2) negative impact, doubted usefulness, and ethical concerns; and (3) resource limitations. Strategies to mitigate these barriers were also explored: (1) accommodate the various needs of residents and health care providers, (2) increase the understanding of the benefits of using robots, (3) review and overcome the safety issues, and (4) boost interest in the use of robots and provide training.

CONCLUSIONS

Previous literature suggested using AI-enabled robots to resolve the challenges of increasing care needs and staff shortages in LTC. Yet, our findings show that health care providers might not use robots because of different considerations. The implication is that the voices of health care providers need to be included in using robots.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-doi:10.1136/bmjopen-2023-075278.

Quality of Work Life and Mental Well-Being for Long-Term Care Staff in Nova Scotia

This study assesses the quality of work life for Nova Scotian continuing care assistants (CCAs) (n = 266), nurses (n = 144) and managers (n = 45) from 10 long-term care (LTC) homes in late 2021. CCAs scored significantly worse than nurses and managers on measures of mental health and anxiety. All groups reported high levels of cynicism and emotional exhaustion; CCAs' scores were higher than nurses or managers. CCAs scored significantly higher on professional efficacy than other groups. CCAs can derive a strong sense of accomplishment from their work, but results raise concerns of a potential breaking point. This suggests the need for continued action to support LTC staff.

Treatment and Care for Nursing Home Residents with COVID-19: A Qualitative Study

Purpose

Coronavirus disease 2019 (COVID-19) placed a significant strain on nursing homes, leading to numerous outbreaks and high mortality rates. This situation created considerable stress and challenges for residents, their physicians and nurses, as well as family caregivers. By understanding these challenges, we can gain new insights and learn valuable lessons. Thus, the purpose of this study is to examine the treatment and care provided to nursing home residents with COVID-19, as experienced by physicians, nurses, and family caregivers.

Participants and Methods

This study is a secondary analysis of 35 interviews with physicians, nurses, and family caregivers, each with personal experience caring for nursing home residents diagnosed with COVID-19. The interviews took place from December 2020 to April 2021. We analyzed the transcriptions based on Braun and Clarke's reflexive thematic analysis model and followed a qualitative descriptive design as outlined by Sandelowski.

Findings

The analysis produced three themes: 1) Balancing medical treatment, 2) The need for increased systematic monitoring of vital functions, and 3) Determining the treatment level for nursing home residents. These themes were explored through the unique perspectives of the three participant groups: physicians, nurses, and family caregivers. The findings revealed several challenges related to treatment and care for nursing home residents diagnosed with COVID-19. This applied both to relief of symptoms, monitoring of vital functions, assessment of treatment level and use of advance care planning.

Conclusion

Drawing from the experiences of physicians, nurses, and family caregivers, there should be a unified plan at the municipal or national level for competency development in nursing homes to prepare for future crises like pandemics or epidemics. Additionally, the safe engagement of family caregivers and relatives should be given priority.

COVID-19 ethics: unique aspects and a review as of early 2024

COVID-19 presents a variety of ethical challenges in a set of arenas, arenas not always considered in past pandemics. These challenges include issues related to autonomy, distributive ethics, and the establishment of policies of equity and justice. Methods are a literature review based on regular editing of an online textbook during the COVID-19 outbreak and a literature review using key ethical terms. Patients are confronted with new issues related to autonomy. Providers need to expand their concepts of ethical issues to include decisions based on proportionality and public health ethics. The public health sector needs to assess the beneficence of alternative modes of disease control. The research community needs to redefine the concept of informed consent in emergent conditions. All elements of the medical spectrum-physicians, scientists, and the community-at-large including the pharmaceutical industry-need to consider the multifaceted methods for preventing future pandemics. This will require giving particular emphasis to public health funding and ending the documented discrimination that exists in the provision of proven therapies. The developing world is especially at risk for most of the ethical issues, especially those related to equity and justice. The ethical issues associated with the COVID-19 outbreak are not unique but provide a diverse set of issues that apply to patients, providers, social groups, and investigators. The further study of such issues can help with preventing future outbreaks.

Insight into the experiences of caregivers of older adults in long-term care homes: A photovoice study

AIMS

To explore the lived experiences of caregivers of people living in long-term care (LTC) homes during the initial phases of the COVID-19 pandemic and potential supports and resources needed to improve caregivers' quality of life.

BACKGROUND

Carers (or care partners) of adults in LTC contribute substantially to the health and well-being of their loved ones by providing physical care, emotional support and companionship. Despite their critical role, little is known about how caregivers have been impacted by the pandemic.

DESIGN

An interpretive descriptive approach that incorporated the photovoice method was used.

METHODS

Using a purposive sampling strategy, six family carers in Ontario, Canada were recruited between September and December 2021. Over a 4-week period, caregivers took pictures depicting their experience of the pandemic that were shared in a virtual focus group. Visual and text data were analysed using thematic analysis with an inductive approach.

FINDINGS

Caregivers expressed feelings of frustration, confusion and joy. Emerging themes included: (i) feeling like a 'criminal' amidst visitor restrictions and rules; (ii) experiencing uncertainty and disappointment in the quality of care of long-term care homes; (iii) going through burnout; and (iv) focusing on small joys and cherished memories.

CONCLUSIONS

The combination of visual and textual methods provided unique insight into the mental distress, isolation and intense emotional burdens experienced by caregivers during the pandemic.

IMPACT

Our findings underscore the need for LTC organizations to work in unison with caregivers to optimize the care of residents and support the mental health of caregivers.

REPORTING METHOD

This work adhered to the consolidated criteria for reporting qualitative research (COREQ) checklist.

PUBLIC CONTRIBUTIONS

The caregivers included in the study were involved in the co-creative process as active contributors informing the design and validation of the codes and themes.

Workforce resilience supporting staff in managing stress: A coherent breathing intervention for the long-term care workforce

BACKGROUND

Staff in long-term care (LTC) homes have long-standing stressors, such as short staffing and high workloads. These stressors increased during the COVID-19 pandemic; better resources are needed to help staff manage stress and well-being. The purpose of this study was to evaluate the effect of a simple stress management strategy (coherent breathing).

METHODS

We conducted a pre-post intervention study to evaluate a self-managed coherent breathing intervention from February to September 2022. The intervention included basic (breathing only) and comprehensive (breathing plus a biofeedback device) groups. Six hundred eighty-six participants were initially recruited (359 and 327 in the comprehensive and basic groups respectively) from 31 LTC homes in Alberta, Canada. Two hundred fifty-four participants completed pre-and post-intervention questionnaires (142 [55.9%] in comprehensive and 112 [44.1%] in basic). Participants were asked to use coherent breathing based on a schedule increasing from 2 to 10 min daily, 5-7 times a week over 8 weeks. Participants completed self-administered online questionnaires pre- and post-intervention to assess outcomes-stress, psychological distress, anxiety, depression, resilience, insomnia, compassion satisfaction, compassion fatigue, and burnout. We used a mixed-effects regression model to test the main effect of time (pre- and post-intervention) and group while testing the interaction between time and group and controlling for covariates.

RESULTS

We found statistically significant changes from pre- to post-intervention in stress (b = -2.5, p < 0.001, 95% CI = -3.1, -1.9), anxiety (b = -0.5, p < 0.001, 95% CI = -0.7, -0.3), depression (b = -0.4, p < 0.001, 95% CI = -0.6, -0.2), insomnia (b = -1.5, p < 0.001, 95% CI = -2.1, -0.9), and resilience (b = 0.2, p < 0.001, 95% CI = 0.1, 0.2). We observed no statistically significant differences between the two intervention groups on any outcome.

CONCLUSIONS

Our findings suggest that coherent breathing is a promising strategy for improving stress-related outcomes and resilience. This intervention warrants further, more rigorous testing.

Depression, professional self-efficacy, and job performance as predictors of life satisfaction: the mediating role of work engagement in nurses

Background

The life satisfaction and job performance of nursing professionals are affected by a multitude of factors, including work engagement, self-efficacy, and depression. The Job Demands-Resources (JD-R) model provides a theoretical framework to explore these relationships.

Objective

Our study aimed to analyze the primary goal of this research, which is to examine the mediating role of work engagement in the relationship between depression, professional self-efficacy, job performance, and their impact on life satisfaction in nurses, using the JD-R theory as a guide.

Methods

This cross-sectional study involved 579 participants aged between 21 to 57 years (M = 39, SD = 9.95). Mediation analysis was used to examine the influence of depression, self-efficacy, and job performance on work engagement, and in turn, its effect on life satisfaction.

Results

Findings indicated that work engagement plays a crucial mediating role between depression, self-efficacy, job performance, and life satisfaction. Interventions to increase work engagement could assist nurses in better managing depression and improving their performance and life satisfaction.

Conclusions

Our study highlights the need for workplace policies and strategies that foster work engagement and self-efficacy among nurses while effectively managing job demands to prevent depression. Moreover, these findings underscore the importance of the JD-R theory to understand and improve nurses' job satisfaction and performance, and suggest areas for future research, including exploring other potential factors and applying these findings across different contexts and cultures.

The use of the evidence-based practice process by experienced registered nurses to inform and transform clinical practice during the COVID-19 pandemic: A longitudinal national cohort study

BACKGROUND

During the COVID-19 pandemic, many registered nurses (RNs) worked on the frontline caring for severely ill patients. They did so with limited knowledge of how to treat and prevent the disease. This extreme situation puts pressure on RNs to find evidence on which to base the care of their patients.

AIMS

To examine: (1) the extent to which evidence-based practice (EBP) process was applied by Swedish RN cohorts 15-19 years after graduation during the pandemic, (2) whether there was any change to their EBP process from pre-pandemic to late pandemic, (3) the relationship between RNs' use of the EBP process and the duration of exposure to work situations severely affected by the COVID-19 pandemic, and (4) whether level of education, position and care setting were associated with the extent of RNs' EBP process.

METHODS

In 2021, the level of EBP activities was investigated among 2237 RNs 15-19 years after graduation. The scale used to measure EBP consisted of six items of the EBP process. Unpaired t-tests or one-way analysis of variance (ANOVA) were used in the analysis.

RESULTS

RNs used the EBP process to a moderate extent to inform and transform their clinical practice. There was a minor but significant decrease in practicing the EBP process from pre-pandemic to late in the pandemic. RNs who were most affected by the pandemic scored higher on the scale than less-affected colleagues. RNs in nonclinical positions reported more EBP activities, as did RNs in management positions. RNs working in outpatient settings reported more EBP activities than their colleagues in hospitals.

LINKING EVIDENCE TO ACTION

It is imperative that RNs hone their skills in EBP if they are to be prepared for future healthcare crises. Healthcare providers have a duty to facilitate the development of EBP and, in this regard, RNs in clinical positions in hospitals need particular support.

Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis

Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.

Health Provider Experiences in Supporting Social Connectedness Between Families and Older Adults Living in Long-Term Care Homes

Introduction

Many people, often older adults, living in long-term care homes (OA-LTCH) became socially isolated during the COVID-19 pandemic due to variable restrictions on in-person visits and challenges associated with using technology for social connectivity. Health providers were key to supporting these OA by providing additional care and facilitating their connections with family using technology such as smartphones and iPads. It is important to learn from these experiences to move forwards from the COVID-19 pandemic with evidence-informed strategies that will better position health providers to foster social engagement for OA-LTCH across a range of contextual situations.

Objective

This exploratory qualitative description study sought to explore health provider experiences in supporting social connectedness between family members and OA-LTCH within the COVID-19 context.

Methods

Qualitative, in-depth semistructured interviews were conducted with 11 health providers.

Results

Using inductive qualitative content analysis study findings were represented by the following themes: (a) changes in provider roles and responsibilities while challenging for health providers did not impact their commitment to supporting OA-LTCH social and emotional health, (b) a predominant focus on OA-LTCH physical well-being with resultant neglect for emotional well-being resulted in collective trauma, and (c) health providers faced multiple challenges in using technology to support social connectivity.

Conclusion

Study findings suggest the need for increased funding for LTC to support activities and initiatives that promote the well-being of health providers and OA living in LTC, the need to prioritize social well-being during outbreak contexts, and more formalized approaches to guide the appropriate use of technology within LTC.

Working Experiences of Care Aides in Long-Term Care Institutions Following the Relaxation of COVID-19 Regulations in Taiwan: A Qualitative Study

Care aides in long-term care (LTC) institutions care for older disabled residents at high risk for COVID-19. However, they experienced many stressors during the COVID-19 pandemic. This study aims to explore the working experiences of care aides in LTC institutions following the relaxation of COVID-19 regulations in Taiwan. This qualitative descriptive study included 20 care aides who had cared for residents with COVID-19. Data were obtained via semi-structured interviews. Caring for residents with COVID-19 and the difficulties, resources and teamwork, and impact of care aides' work on their lives were discussed. Consequently, four themes were identified. First, difficulties in care, which included physical limitations by protection, workload, and impact of work schedule on the lives of the care aides. Second, psychological impact, such as worry, social isolation, and burnout. Third, interpersonal relationships with supervisors, colleagues, residents, and their families. Fourth, infection control policy from the institution and government. When infection control policies were relaxed, care aides had difficulties in caring for residents; furthermore, their family and social lives were also affected. They were required to learn knowledge of and skills for COVID-19 management. Institutions were required to provide support in materials, care processes, environment, and management.

"We are still tired": staff and administrators' experiences during the COVID-19 pandemic within California residential care facilities for older adults

BACKGROUND

Extensive research has been conducted on the impacts of the COVID-19 pandemic on long-term care workers in specialized care facilities. However, little is known about the impacts faced by facilities that provide generalized long-term support and care, such as residential care facilities for older adults (RCFs). This study describes the challenges experienced by staff and administrators of RCFs during the COVID-19 pandemic.

METHODS

An electronic questionnaire collecting data using both closed- and open-ended questions on staff experiences was sent to 5,721 unique RCF administrator emails within the state of California between June-December 2021. Email addresses were obtained from the public database of RCFs available through the California Health and Human Services Open Data Portal. Descriptive statistics were calculated on quantitative data regarding staff preparedness training, access to resources, and administrators' confidence in meeting recommended guidelines during the pandemic. Inductive thematic analysis was conducted on qualitative data regarding the confidence levels in meeting pandemic guidelines and challenges faced related to staff stress and morale.

RESULTS

A total of 150 RCF administrators across California (response rate of 2.6%) completed the survey. Over three-fourths of respondents indicated their facilities had a designated staff member to train other staff members on emergency preparedness plans and the most frequently used resources during the COVID-19 pandemic were the Department of Social Services Community Care Licensing Division (88.7%), the county health department (86.7%), and the Centers for Disease Control and Prevention (80.7%). Administrators felt least confident in their facilities' ability to maintain adequate staffing (52.0%), communication with nearby hospitals (62.1%) and communication with state and local public health officials (69.8%) during the pandemic. Three central themes emerged from the thematic analysis on staff stress and morale: (1) physical safety, mental and emotional impact of the COVID-19 pandemic; (2) staffing issues; and (3) challenges with guidelines in managing the ongoing pandemic.

CONCLUSIONS

Findings from this research study can be used to actively target training resources for facility administrators and staff that have been identified as most frequently used and relevant for emergency preparedness in these understudied facilities. Additionally, developing a better understanding of the staffing stress and morale difficulties in RCFs can provide insight on how policymakers can assist these critical facilities in better preparing for future crises.

Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic

Importance

Staffing shortages have been widely reported in US nursing homes during the COVID-19 pandemic, but traditional quantitative research analyses have found mixed evidence of staffing shortfalls.

Objective

To examine whether nursing home administrator perspectives can provide context for conflicting aggregate staffing reports in US nursing homes during the COVID-19 pandemic.

Design, Setting, and Participants

In a qualitative study, convergent mixed-methods analysis integrating qualitative and quantitative data sets was used. Semistructured qualitative interviews were conducted between July 14, 2020, and December 16, 2021. Publicly available national Payroll Based Journal data were retrieved from January 1, 2020, to September 30, 2022, on 40 US nursing homes in 8 health care markets that varied by region and nursing home use patterns. Staffing and resident measures were derived from Payroll Based Journal data and compared with national trends for 15 436 US nursing homes. Nursing home administrators were recruited for interviews. Of the 40 administrators who consented to participate, 4 were lost to follow-up.

Exposure

Four repeated, semistructured qualitative interviews with participants were conducted. Interview questions focused on the changes noted during the COVID-19 pandemic in nursing homes.

Main Outcomes and Measures

Thematic description of nursing home administrator compensatory strategies to provide context for quantitative analyses on nursing home staffing levels during the COVID-19 pandemic.

Results

A total of 156 interviews were completed with 40 nursing home administrators. Administrators reported experiencing staff shortages during the COVID-19 pandemic and using compensatory strategies, such as overtime, cross-training, staff-to-resident ratio adjustments, use of agency staff, and curtailing admissions, to maintain operations and comply with minimum staffing regulations. Payroll Based Journal data measures graphed from January 1, 2020, to September 30, 2022, supported administrator reports showing that study facilities had reductions in staff hours, increased use of agency staff, and decreased resident census. Findings were similar to national trends.

Conclusions and Relevance

In this qualitative, convergent mixed-methods study, nursing home administrators reported the major staffing strain they experienced at their facilities and the strategies they used to offset staffing shortages. Their experiences provide context to quantitative analyses on aggregate nursing home census data. The short-term compensatory measures administrators used to comply with regulations and maintain operations may be detrimental to the long-term stability of this workforce.

Providing Care During the COVID-19 Pandemic: The Experience of Formal Caregivers in Long-Term Care Facilities in Chile

The current study aimed to identify the main challenges to formal caregivers from different long-term care facilities (LTCFs) that care for older adults (aged ≥60 years) in Chile during the coronavirus disease 2019 pandemic. Chile's national LTCF governing body (SENAMA) sent a survey to 1,190 LTCFs, receiving 996 responses. LTCF characteristics were number of residents, certification with SENAMA, licensure, geographic zone, and poverty level. Four dimensions were assessed: (a) concerns, (b) challenges, (c) needs, and (d) opportunities for improvement. The majority of respondents replied negatively to these four dimensions. Among those who responded positively, the fear of infecting a loved one, staff shortages and overwork, the need for access to psychological support, and improving payments were among formal caregivers' primary concerns. Targeting supportive interventions for formal caregivers, clinically and psychologically, is essential to preserve caregivers' health. [Journal of Gerontological Nursing, 49(5), 39-44.].