In the study "Stress and coping strategies of nursing professionals at the beginning of the COVID-19 crisis in the field of inpatient long-term care", you interviewed nursing professionals about their experience in the first wave of 2020 in Berlin. What stresses did the nursing professionals face during this time? Which stresses were particularly hard?
Gudrun Piechotta-Henze: First of all, I would like to briefly explain why we focused the study on the first wave of the COVID 19 crisis (end of March to beginning of May 2020) and exclusively on the target group of skilled nursing staff in inpatient geriatric care. Although many other stressful periods and circumstances occurred, the first wave is likely to have been particularly memorable. It was the time of greatest uncertainty; neither society and politics nor healthcare workers and facilities had ever been confronted with such a situation. Accordingly, there was a lack of experience and knowledge; moreover, vaccinations did not yet exist and the necessary hygienic and protective equipment, such as face masks, protective gowns and disinfectants, was simply lacking. For the first time, we also experienced a lockdown in the Federal Republic of Germany, especially the infection and death rate among the elderly was high and the people, residents, relatives and staff, had to deal with contact bans in the facilities. These completely new situations, so we thought, offered the handling of crises and how they are managed. In this respect, we also wanted to take a look at resources and what opportunities emerge to learn from this crisis.
The study group, nursing staff in the inpatient geriatric care sector, was determined by us when we realized that only very few studies had examined this very group. In other words, one could also formulate: Once again, much has been said and written about professional nurses, but they themselves have not had their say. I.e., with our study we also wanted to give nurses a voice, to ask them directly what stresses they experienced and how, but also how they coped with them.
Which stresses were described by the nurses? For them, the focus was on the aspects already briefly mentioned above: There was too little or no protective clothing. Sometimes nurses sewed masks themselves or had them sewn. Above all, however, the COVID 19 crisis in the geriatric care sector hit a work setting that is already affected by high work compression and staff shortages. Accordingly, staff shortages are cited as the greatest burden in the first wave. Many colleagues have to stay at home due to corona infections. The situation is aggravated by the fact that relatives are not allowed to enter the facilities. Their important support is therefore lost, as is that of the everyday helpers and therapists. There are occasional cases of serious illness among colleagues, but above all among residents, and in some facilities even deaths. The dying phases of the people entrusted to them are an impressive burden for the nurses. They would like to accompany them professionally, but the extra work, the lack of time and personnel prevent care at the end of life, holding hands, sitting by the bed, a last conversation, a silence with each other. This is hardly bearable for many, especially since the loneliness of the dying goes side by side with the loneliness of the living. The residents, especially those with dementia, become lonely during this time, they miss the regular and familiar visits, for example of their children. They are also irritated by the fact that meals are no longer shared, that they are not supposed to leave their room, and that the person opposite them covers their face with a mouth/nose shield so that no facial expressions can be seen. The caregivers report that, as a result, there has been an increase in aggressive behavior, emotional withdrawal and rapidly progressing physical limitations. Relatives are also distressed, often understanding, but sometimes demanding and aggressive. The staff must repeatedly ask for patience and understanding, take numerous telephone calls, accept and pass on clothing, food, gifts from relatives, for example for the mother or spouse, in the entrance area.
In addition to all this stress in the first wave, there is also a lack of expertise in dealing with a pandemic, as well as the daily reading and observance of short-term, sometimes contradictory orders and recommendations from the various political and health-related institutions (e.g., the Federal Ministry of Health, the Robert Koch Institute, the Senate, and the Workers' Compensation Board).
"We therefore say that counseling and support services must become a matter of course in the care sector, as mandatory services and counted as working time."
What helped caregivers get through this time, what resources were available to them?
Annina Böhm-Fischer: The previous literature analysis clearly showed that what was perceived as resources was when team cohesion and support within the team improved during the pandemic and when there was trust in the measures taken by the home's management. As a result, the working atmosphere was perceived to be better and everyone helped each other. The appreciation by the society as well as by the employers_ was also described as a resource. Our empirical study confirms these statements and adds valuable aspects. We found that external support from the German Armed Forces - as test assistants - was helpful, but that external leasing staff were not perceived as a relief. Appreciative conversations with relatives as well as with the management were defined as a resource, together with the feeling of reliability and togetherness. Constructive conflict resolution and independent scheduling of breaks were also valuable during the period of increased stress, as other resources such as sufficient relaxation during free time often fell short. Many were not even able to retire after their shifts because the children were virtually in the home office. Schools were closed for weeks and then at home lessons had to be made up in online mode, chores had to be supervised.
What individual solutions to problems did the caregivers find. Can you give examples?
Annina Böhm-Fischer: Unfortunately, there were rather few individual solutions to problems, but this is also due to the problem itself - you can't solve the effects of a pandemic on your own. In the literature, in further studies, only little was reported about coping with stress, psychological or social support by colleagues and superiors seems to have been asked only marginally or not at all.
As already noted, no one in our study was able to fall back on professional support services either; all of them resorted to private relief options, so to speak. They mentioned reading books, their social and family contacts in private life, conversations with friends and acquaintances, and sports.
In the inpatient long-term care facilities, private terminals enabled contact between residents and relatives. This did not solve the actual problem, the visiting ban, but the subjective burden on the caregivers as well as the irritation and loneliness of the residents was alleviated. It is also worth mentioning that one solution to the problem that was perceived as positive was to refer relatives to the management level, even though the latter also had to do a lot of extra work.
What professional support services would have been needed?
Olivia Dibelius: Professional work needs professional supervision, counseling, crisis support services. Especially people in the health care sector who are committed to the health of others also need to stay healthy themselves. In the nursing sector, stress levels are already high for a variety of reasons, and the COVID 19 crisis brought previous and new problem situations to a head. We therefore say that counseling and support services must become a matter of course in the care sector, as mandatory services and counted as working time. In addition, preventive and health promotion services must be made available.
Did interviewees leave their profession after experiencing the pandemic?
Olivia Dibelius: Actually, there was a surprise here, the nursing professionals interviewed would like to stay in the profession. Although they associate the first wave in particular, the COVID-19 crisis overall, with high psychological, social and physical stresses, almost no one reported thinking about leaving the profession temporarily or permanently. Above all, the teamwork, the closeness to people, the communicative and interactive aspects of the job could not be offered by any other field of work. While they all longed for an end to the pandemic and the challenges that come with it, these interpersonal, social parts of the job would be of high value to them.
How do working conditions have to change so that nurses can work better?
Gudrun Piechotta-Henze: First and foremost, there needs to be a paradigm shift. Nursing is a highly complex - system-relevant - activity that, as such, finally deserves the social and political recognition it deserves. This also entails professional counseling and coping services - especially in times of crisis, but not exclusively. The study has made it clear that nurses accomplish a great deal, but coping with their tasks and the immense burdens is still seen as a female job. There is also a need for social empowerment, such as lobbying in political organizations and having a say in the health care system - especially in challenging times.
Basically, working conditions in (geriatric) care must change, including appropriate staff development and staffing levels, as well as changed working hours and new definitions of nursing tasks. It is essential to ensure adequate pay based on collective bargaining agreements, as well as the best possible training and career paths.
Further information The study "Stresses and coping strategies of nursing staff at the beginning of the COVID-19 crisis in the field of inpatient long-term care" is available in open access. Gudrun Piechotta-Henze is professor of nursing science.