The coronavirus disease 2019 (COVID-19) pandemic in nursing homes – the experience of care workers in Poland

Backgrounds

The COVID-19 pandemic had serious consequences for public health and also caused a number of secondary impacts, such as the need to maintain social distancing, remote work and education, a travel ban, and the need to stay in solitary confinement. The consequences of the pandemic also include a change in individual well-being (see, among others, Emiliani et al., 2020; Pišot et al., 2020; Krajewski et al., 2021) and the quality of public services provided. The second of these areas is the subject of this article, and nursing homes are an example of a space where the effects of the pandemic were experienced particularly in the area of service provision. As these institutions provide 24-hour care, they could not be closed and so both their employees and residents functioned under conditions of epidemic threat.

The conducted empirical research was to partially fill the gap in knowledge about the condition of care workers in Poland during the coronavirus pandemic. However, we have consciously gone beyond the narrow analysis of public statistics and taken account of the social aspect of the pandemic. This research is based on the culture-of-disaster perspective (see, among others, Revet, 2020; Revet & Langumier, 2015; Bankoff, 2003; Medina, 2016; Benadusi, 2014), which focuses on ‘what disaster is made of for each of the actors involved’ (Revet & Langumier, 2015). The subject of interest is the attitudes toward the crisis situation shared by individuals, including how they experienced the reality of the pandemic. Etienne Wenger adds that the relations between the functioning of asocial system and the orientations toward it are shaped within the community of practice (Wenger, 1998). These practices are revealed not only in action, but also through the shared knowledge, attitudes and beliefs that create a certain common view of the world (Wenger, 1998, p. 47).

It can therefore be asked why, in the proposed cultural approach, the experiences of care workers should be considered important? Firstly, the knowledge of practitioners should be treated as a social mirror of the resourcefulness of institutions in the crisis caused by the pandemic. The capacity to deliver care services in a pandemic situation may be extended along the continuum between two poles as defined by Nilsson and Olaison: suspension versus seeking new solutions (Nilsson & Olaison, 2020). Of course, care institutions fulfilled their basic functions despite significant difficulties in operating during the successive waves of the pandemic. However, it is worth referring to the experience of practitioners and asking about the ability to meet the caring, activating, religious and other needs of nursing home residents during the pandemic. This question is answered in the first part of the article, which presents nursing homes employees’ assessments of the individual assistance measures.

Secondly, the analysis of employees’ experiences may become the basis for formulating recommendations on changes in the care system. The previous analyses are dominated by the belief that the pandemic should be treated as a wake-up call (Fischer et al., 2020) in the face of the challenges of an aging society. The academic discourse calls for necessary reforms to ensure high-quality care for people with limited independence in the future (Daly, 2020). When planning social policies (Rothman, 2007), it is worth listening to the needs of those who faced the consequences of the pandemic on a daily basis. Based on the analysis of expectations and preferences regarding the protection of mental health, a proposal for changes is presented that would enable better preparation for possible crisis situations caused by the need to work in an emergency.

To sum up, the research carried out in the group of care workers allows the voice of those whose positions in the public discourse are not properly articulated to be captured. On the one hand, they do not have enough time to shape their own narrative in the public discourse as they simply deal with duties related to care and its organization. During the pandemic, this care is even more demanding than before (Fallon et al., 2020; Rodrigues et al., 2021). On the other hand, care workers frequently lack representation because they have a ‘silent voice’ due to poorly organized trade unions and employee organizations in comparison with the healthcare sector, among others (Daly, 2020).

Survey

The field research was carried out in April 2021. It was conducted using the computer-assisted web interviewing (CAWI) technique. The CAWI questionnaire consisted of 19 questions grouped in following topics: mental well-being of employees, internal rules of the functioning of the institution, residents’ needs, cooperation with the environment, birth certificate questions. The questionnaire can be found as Extended data (Necel, 2022). The questionnaire hasn’t been validated.

The CAWI technique was chosen because it provides easy access to the population, which was particularly important during the pandemic due to the need to maintain social distancing. Moreover, this tool allows the avoidance of open-ended questions and questions formulated primarily in the form of statements, making it useful in this project. The link to the questionnaire, along with a covering letter, was sent to the secretariats of nursing homes with a request that two care workers fill in the questionnaire, so that there is no imbalance in the number of questionnaires received between institutions with different numbers of employees. The inclusion criteria (verified by the answers given to the corresponding survey questions) included being engaged in work during the COVID-19 pandemic to April 2021. The exclusion criterion was being an employee who was not a care worker, e.g. an accountant.

Ethical considerations

The Ethics Committee for Research Involving Human Participants at Adam Mickiewicz University in Poznan granted an approval of the research project (Resolution No. 4/2021/2022 adopted on 25 January 2022). Each research participant signed a voluntary and informed consent form for participation in the research. We uploaded “consent form” to a repository.

Sampling of participants

The research used a non-probability purposive sampling asit was carried out on a relatively small population with a well-known structure with the possibility of accessing all its representatives.

The research was carried out in all nursing homes in five provinces in Poland (there are a total of 16 provinces in Poland): 54 nursing homes in Lower Silesia, 55 in the Lodz Province, 47 in the Subcarpathian Province, 44 in the Lublin Province and 62 in the Greater Poland Province. The provinces were selected for the research based on the analysis of the following variables: the number of nursing homes, the number of places in these homes, the number of residents and the number of employees. On this basis, provinces with similar care resources were selected. The employee population involved: management staff, administration workers and care workers, which included social workers, nurses and therapists, that is, representatives of the profession providing direct support and help to residents of nursing homes.

Statistical analysis

A chi-square test (with Yates’ correction for 2×2 tables) was used to compare qualitative variables among the groups. In the case of low values in the contingency tables, Fisher’s exact test was used instead. The level of significance for all statistical tests was set at 0.05. Thus, all p values below 0.05 were interpreted as showing significant correlations. R 4.0.5 was used for the computations (RRID:SCR_001905).

The studied group of care workers

By the end of 2020, 37,309 care workers were employed in Poland. In the five voivodships surveyed, a total of 18,659 carers were employed. The research was conducted among 189 of them (Ministry of Family and Social Policy, 2022). The coverage rate, calculated based on the ratio of the total number of employees of nursing homes in the five provinces to the number of people participating in the research, is 1.01%. Employees representing three types of care facilities participated in the research: nursing homes for people with mental disorders – 36.5%, nursing homes for people with reduced mobility – 36.5%, and nursing homes for the elderly – 27.0%. The nursing homes whose employees took part in the research were located primarily in urban municipalities – 56%, followed by urban-rural municipalities – 19.8%, and rural municipalities – 24.2% (Table 2).

Respondents were most often care workers – 44.9% (of whom 18.6% were nurses) and slightly less often management staff – 29.9%, while 21.6% of all respondents were administration workers. As a rule, respondents had extensive work experience in the social welfare sector. Over one-third (36.2%) had more than 20 years of work experience. There was also a large group of employees with 10 to 19 years of work experience, who constituted 33.3% of all respondents. Only 11.9% of respondents had less than two years of work experience, and 18.6% of the surveyed nursing home employees had been employed for two to nine years.

Perception of the services provided in nursing homes

Respondents were asked to assess to what extent the basic needs of residents were met during the pandemic (Table 3). The question was accompanied by multiple-choice answers detailing the various activities of care institutions in this area. Most respondents assessed the fulfillment of the basic living needs of residents (food, clothing, hygiene products) as definitely good (78.3%) and somewhat good (20.6%). Similarly, the represented institutions were rated highly in terms of the availability of care and support services. The implementation of this function was assessed as definitely good by 64.6% of respondents, or as somewhat good by 32.8%. In other aspects of the functioning of the nursing homes, respondents had more diverse opinions. When it comes to organizing the leisure time of residents, 24.3% assessed it as definitely good, and 46.6% as somewhat good. On the other hand, 14.3% of respondents were of the opposite opinion and answered ‘somewhat bad’ or ‘very bad’. Just over half of respondents (54.5%) assessed the fulfillment of religious and cultural needs as definitely good or somewhat good, and about one-fifth of respondents had the opposite opinion (22.8% – the cumulative percentage of answers ‘somewhat bad’ and ‘very bad’). In the context of the restrictions introduced on visits by outsiders during the pandemic, it is surprising that 21.2% of respondents assessed activities related to maintaining and developing contact with family and the social environment as definitely good and as many as 42.9% as somewhat good. It is worth emphasizing, however, that over one-fifth of respondents had a different opinion (21.2% – the cumulative percentage of answers ‘somewhat bad’ and ‘very bad’), and 14.8% of employees did not have an opinion on this subject. The activities of care institutions for the benefit of the local community were rated the least positively, as 5.3% answered ‘definitely good’, 18% ‘somewhat good’, and as many as 55.6% of respondents did not express an opinion on this subject.

The statistical analyses conducted (chi-square test or Fisher’s exact test) showed that the assessments of the functioning of nursing homes during the pandemic were different depending on the respondents’ job position. Significant differences were noted in the opinions regarding the fulfillment of religious and cultural needs (p < 0.001, probability value < 0.05), the implementation of which was assessed as definitely good (28.4%) and somewhat good (33.3%) by care workers, while only 2% of directors expressed an overwhelmingly positive opinion, and 38%a somewhat positive opinion about this aspect. The job position also differentiated the views on maintaining contact with the family and the social environment (p = 0.034, probability value < 0.05). In this case, care workers were also more optimistic in their assessments. This aspect was assessed as definitely good by 29.6%, or as somewhat good by 39.5%. Only 10% of management representatives gave a similar opinion, responding ‘definitely good’, and 40% responded ‘somewhat good’. The job position was also important when assessing activities undertaken for the benefit of the local environment (p = 0.008, probability value < 0.05). As was the case with the above dependencies, this time care workers were also more satisfied than the management of the facility. While 8.6% of care workers assessed this function as definitely good and 17.2% as somewhat good, only 2% of the management staff assessed it as definitely good and14% as somewhat good.

In the course of the analyses, the hypothesis has been confirmed that the type of nursing home in which an employee works significantly differentiates the assessment of the functioning of the care institution in the context of meeting the basic needs of residents. A statistically significant relationship was noted in the area of providing care and support services (p = 0.009, probability value < 0.05). Namely, 73.9% of employees of nursing homes for people with mental disorders assessed this aspect of activity as definitely good. In the case of nursing homes for the elderly, 66.6% of answers were definitely good, while in the case of nursing homes for people with reduced mobility, this number was 53.6%. The differentiation also concerned the organization of leisure time for residents (p = 0.002, probability value < 0.05). Namely, 37.6% of respondents from nursing homes for people with mental disorders expressed a definitely good opinion about this form of support. Only 23.5% of the representatives of nursing homes for the elderly and 11.5% of respondents from nursing homes for people with reduced mobility were of a similar opinion. Significant differences were also noted in terms of maintaining and developing contact with family and the environment (p = 0.046, probability value < 0.05). They were assessed the best by the representatives of nursing homes for people with mental disorders (27.5% definitely good, and the worst by respondents from homes for people with reduced mobility (13% definitely good). The analyses of statistical dependencies did not show that the type of municipality or the respondent’s seniority statistically significantly differentiated the assessment of the functioning of a care institution.

The most stressful factors at work during the pandemic

Respondents were asked about the most stressful factors at work since the declaration of the pandemic (Table 4). The surveyed nursing home employees most often indicated the necessity to work under the conditions of health risk as a stressful factor. This answer was given by 68.3% of respondents.

Another stressful factor for respondents was their responsibility for the residents of nursing homes, which was emphasized by 62.4%. Other stressors were mentioned less frequently. More than one-third of respondents (35.4%) mentioned combining work with duties toward their relatives, such as taking care of children and other dependent family members. In the light of the empirical data obtained, unclear procedures in the pandemic situation also turned out to be stressful at three levels: national, local and at the level of the institution where respondents worked. Nearly one-third of respondents pointed to the lack of clear procedures at the national level (32.8%). Interestingly, the lack of clear procedures at the local level was indicated as a stressful factor by 9.5% of respondents, while unclear procedures inside an institution were pointed out by 4.2%.

Responsibility for others outside the workplace was a stressful factor for almost every fourth respondent (24.3%). However, for every fifth respondent (19%), stress and tension resulted from the limited possibility of testing for the presence of coronavirus. The lack of or too little personal protective equipment (PPE) in the workplace was selected as a stressor by only 4.2% of respondents.

Conflicts emerging due to tension in the workplace were stressful for 18% of respondents, while in their private life it was 2.1% and thus the least frequently chosen stress factor.

The analyses conducted (chi-square test and Fisher’s exact test) have confirmed the hypothesis that opinions about stressors differ depending on seniority. Statistically significant differences were noted in the opinions on combining work with responsibilities toward loved ones (p = 0.005, probability value < 0.05). This issue was mentioned by 57.5% of respondents with work experience from three to nine years, and only by 19% of those with work experience of up to two years. Seniority significantly differentiated the employees in their statements about unclear procedures at the local level (p = 0.026, probability value < 0.05), which was a source of stress mainly for respondents with up to two years of experience, among whom 28.5% pointed to this problem. However, this factor was stressful for only 9.3% of people with the longest work experience (20 years and more). The analyses have also confirmed the hypothesis about the relationship between the position held and the importance given to unclear procedures at the local level (p = 0.029, probability value < 0.05). This problem was much more often emphasized as stressful by administration employees (11.1%). None of the management staff representatives indicated the importance of this factor. However, the sense of responsibility for the residents (p < 0.001, probability value < 0.05) was much more likely to be a stressor for institution directors (88%) than for administration employees (47.2%) or care workers (56.7%).

There were no statistically significant correlations confirming the hypothesis about differences in the perception of stressors depending on the type of the municipality represented or the type of nursing home.

Perception of mental health

The question about stress factors at work corresponds to another research problem concerning the mental health of nursing home workers during the pandemic (Table 5). Respondents were asked a series of questions based on the following template ‘Did you … in the months since the outbreak of the pandemic?’ with selected areas of wellbeing clarified. They were asked to respond based on the following multiple-choice answers: ‘much more than usual’, ‘slightly more than usual’, ‘the same as usual’, ‘slightly less than usual’ and ‘much less than usual’. Areas of particular interest were those that changed during the pandemic and so the cumulative percentages of the responses ‘much more than usual’ and ‘slightly more than usual’ are presented to describe the results.

The research results indicate the widespread experience of increased stress among nursing home employees. Over 84% of respondents felt more stressed than usual on a daily basis. The vast majority of respondents (over 70%) felt motivated to act at that time. Most respondents also experienced chronic fatigue (82%), and more than half had trouble sleeping (54%).

The intensity of neurotic reactions was also greater than usual. Almost 70% of research participants felt more anxiety or severe anxiety than usual. Over 60% of respondents felt increased nervousness and tension in contacts with people.

The studied individuals relatively less frequently manifested selected depressive reactions in the form of cognitive changes consisting of perceiving the situation as hopeless (less than 50%) and the inability to experience pleasure (slightly over 33%).

The hypothesis that psychological wellbeing is related to the position held has been confirmed by the analysis of statistical correlations in only one aspect, that is, the mobilization to act (p < 0.001, probability value < 0.05). It was felt most strongly by directors, as many as 68% of whom felt it much more than usual, and the weakest by administrative employees, only 25% of whom were mobilized to act much more than usual. It turns out that the differences in the mobilization to act were also influenced by the type of nursing home in which a respondent works (p = 0.013, probability value < 0.05). The mobilization function of the pandemic was higher in facilities for the elderly, where 45.1% of respondents felt this much more than before the pandemic, while in facilities for people with reduced mobility and mental disorders, it was 36.2% and 40.5%, respectively. The hypothesis that the type of municipality represented differentiates the psychological wellbeing of respondents has also been confirmed. Statistically significant differences were noted in the case of nervousness in contacts with others (p = 0.015, probability value < 0.05), which was felt much more than usual by nursing home employees from urban-rural municipalities (27.7%) than by those from rural (13.6%) or urban (7.8%) ones.

Protection of mental health: available and expected forms of support for care workers

In the research, respondents were asked about solutions used in their workplaces to protect mental health (Table 6). For this purpose, respondents were asked the following closed-ended question: ‘What solutions have been implemented to protect the mental health of people working in your institution?’ The following forms of support were distinguished among the responses: ‘conversation with a psychologist’, ‘support group’, ‘supervision’ and ‘other’. Over one-third of respondents (37%) did not record any activities in their institution aimed at protecting mental health during the pandemic. This means they did not choose any of the possible answers. Among 63% of respondents who thought that their institution had implemented support instruments, most mentioned a conversation with a psychologist. Such a solution was observed by over one-third (35.4%) within their institution. According to some respondents, the institutions also organized support groups. This type of assistance was indicated by approximately one-fifth of respondents (21.7%). Moreover, 7.4% of respondents could have performed their work under supervision, which can also be classified as a solution aimed at protecting mental health. Finally, 11.1% of respondents indicated other types of support.

The analysis of statistical correlations performed using the chi-square test did not show significant differences in the opinions on the forms of psychological support provided depending on the position held, seniority, the type of nursing home and the type of municipality in which the facility was situated.

Respondents were also asked the following question about their expectations toward the preferred forms of support for mental wellbeing: ‘What kind of activities aimed at protecting the mental health of employees would you expect in your institution?’ Respondents had the opportunity to express their own expectations toward the represented institution. The empirical material collected was categorized into several responses.

Most respondents (23.8%) expected a conversation with a psychologist. Several times respondents indicated that a psychologist should be from outside the institution, which may result from the reluctance to reveal one’s thoughts to a person one knows due to the lack of anonymity. Support groups were another most frequently mentioned activity aimed at protecting the mental health of employees that, according to the surveyed persons, should have been organized in their institution (11.1%). Another category of answers related to rest or holidays– this was indicated by 6.3% of respondents. Every twentieth respondent (5.2%) indicated the need for the institution to organize training sessions and workshops to help them cope better in the pandemic situation. The same percentage of respondents indicated supervision (5.2%) as well as the need to employ additional people (4.8%). Other responses included expectations related to remuneration (higher salary, bonuses), the role of management (‘clearer decisions of the managers’, ‘support from the managers’) as well as the bodies running the institutions (‘interest of the unit in charge’). There were also references to the situation outside the institutions. Respondents indicated that the following would be helpful: ‘clear procedures at the national level’ or a change in the climate of public opinion, which one of the respondents expressed as: ‘the end of the state of the media pandemic panic’.

Underlying data

Open Science Framework: The Coronavirus Pandemic in Nursing Homes – the Experience of Care Workers in Poland, https://doi.org/10.17605/OSF.IO/72NM4 (Necel, 2022).

Extended data

Open Science Framework: The Coronavirus Pandemic in Nursing Homes – the Experience of Care Workers in Poland, https://doi.org/10.17605/OSF.IO/72NM4 (Necel, 2022).

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).