Psychosocial burden and associated factors among nurses in care homes during the COVID-19 pandemic: findings from a retrospective survey in Germany

The World Health Organization (WHO) declared the spread of the novel Coronavirus (SARS-CoV-2) as a pandemic on the 11^th of March, 2020 [1]. Care homes were hit hard by the pandemic, especially during the first and second pandemic waves. By February 2021, approximately 41% of COVID-19-deaths worldwide were care home residents [2]. In Germany, the estimated share of 50% of all deaths due to COVID-19 was in care home residents only during the first wave of the pandemic [3]. The European Centre for Disease Prevention and Control (ECDC) pointed out that the residents' age and frailty, heterogeneity of staff qualification, lack of personal protection equipment, and SARS-CoV-2-testing possibilities contributed to the high burden of care homes during COVID-19 [4]. Additionally, care homes with many residents, especially those with dementia, may perceive a higher burden due to the pandemic [5, 6]. Problems with implementing hygiene measures, the isolation of residents, and the fear of infection and its possible consequences caused a tense work environment [7, 8]. Therefore, a high psychosocial burden in care home staff was inevitable [3, 6, 9‐11]. A systematic review and meta-analysis on the global psychosocial burden of health care professionals during COVID-19 showed 37%, 41%, and 45% prevalence rates for depression, anxiety, and stress [12]. In Germany, the most extensive study on psychosocial burden and working conditions of health care workers mainly in hospitals found a prevalence of 19% for depression and anxiety [13]. Though evidence for the psychosocial burden among health care workers during COVID-19 is vast, research focusing on care home workers is scarce. To our knowledge, there are three studies reporting prevalence rates of different psychopathological symptoms among care home workers; conducted in Italy, Spain, and the United States [14‐16]. Riello and colleagues found prevalence rates of 22% and 39% for anxiety and Posttraumatic Stress Disorder (PTSD) among 1071 care home workers in Italy [14]. In Spanish care home workers, a prevalence of 49%, 59%, and 71% was found for depression, anxiety, and PTSD, respectively [15]. Further, 35.4% of care home workers in Michigan (United States) reported elevated rates of either PTSD, depression, anxiety, and/or stress [16]. Factors associated with increased psychosocial burden were female gender, knowledge about how to do the job, being a nurse, and contact to staff and/or residents with COVID-19. Moreover, support at work was found to be a protective factor. There are currently no studies evaluating the psychosocial burden of nurses in care homes during the first wave of the pandemic in Germany. Moreover, there is a lack of evidence on what structural factors of care homes and personal factors of nurses are associated with the COVID-19-related burden at work, stress, anxiety, and depression.

Our study aimed to investigate and determine associated factors of psychosocial burden among nurses working at care homes during Germany's first wave of the COVID-19 pandemic.

The present study aimed to investigate stress, anxiety, depression, and COVID-19-related burden at work for nurses in care homes during the first wave of COVID-19 in Germany. Further, we wanted to determine factors associated with the psychosocial burden of nurses in care homes. We have found that COVID-19-related burden was lower in health care assistants, was associated with higher COVID-19-related anxiety, and with dementia as a focus of care. Stress was significantly higher in younger healthcare workers, was associated with higher COVID-19-related anxiety, with increased COVID-19-related work burden and lack of support and sense of community at work. Stress was higher where more COVID-19 cases were diagnosed, but was less in larger care homes. Anxiety and depression were associated with higher COVID-19-related anxiety, with increased COVID-19 related work burden, lack of support, and sense of community at work.

In Comparison to evidence from the Organisation of Economic Co-operation and Development (OECD), providing data on the long-term care workforce of 38 countries worldwide, the present study sample was slightly younger, higher qualified, and more often in a permanent working status [28]. Moreover, 55% of the nurses reported at least one risk factor for a severe course of COVID-19, which is in line with a previous study by Greene and Gibson, which found a similar percentage (50%) of COVID-19 risk factors in the long term care workforce of the United States [29].

Our study supports evidence from other countries that the COVID-19 pandemic had a high impact on working demands and workload of care home staff [7, 8, 11, 30]. In the presen sample, the vast majority of nurses reported an increased working demand since the pandemic, with 42% stating that they were unsatisfied with the COVID-19 management of their care home manager. Prior research showed that care home staff often did not feel involved in decision-making processes and did not feel heard by the management of their care homes. A lack of communication between management and staff caused uncertainty and distress about handling the pandemic and implementing measures to prevent infections [31‐33].

The present study showed increased prevalence rates of stress, anxiety, and depression (59.1%). About 39% of the nurses showed moderate to extremely severe stress symptoms, 36.5% showed clinically significant anxiety, and 41.4% showed clinically significant depression. The prevalence rates found are different from those in Italy, Spain, and Michigan (USA) [14‐16]. In Northern Italy, a prevalence rate of 22% for anxiey was found; 59% for anxiety and 49% for depression were found in Spain. Our findings may be due to the different impacts of the pandemic on countries and structural differences in care homes. Additionally, prior studies included all staff working in care homes, not exclusively nursing staff. Nevertheless, the prevalence rates found in the present study are similar to the meta-analysis on the global psychosocial burden of health care workers during COVID-19 [12]. After analyzing 83 studies, a pooled prevalence of 37% for depression, 41% for anxiety, and 45% for stress among health care workers worldwide were found. Compared to prevalence rates for depression and anxiety found in German healthcare workers in general (19%) and the general population (25%), prevalence rates for depression and anxiety were higher in the present sample [13, 19].

Besides, our findings showed that COVID-19-related burden at work (e.g., lack of personal protection equipment, a small number of COVID-19-Tests for residents and staff) was positively associated with the dissatisfaction with COVID-19 management of care home management, COVID-19- related anxiety, and dementia as a focus of care. This is in line with previous research showing that there was uncertainty about implemented hygiene measures due to a lack of communication and information and not being included in decision-making processes by care home management during the pandemic [8, 31‐33]. A higher burden for care home staff working with residents with dementia, in general, was a concern even before the pandemic [34]. Compared to certified nurses, health care assistants were significantly less burdened due to COVID-19 at work. Prior research showed these ambiguous findings. Some results also imply that health care assistants are less prone to burnout and stress in general and due to COVID-19 than certified nurses [35‐38]. Other studies did not show any differences or even the opposite [39, 40].

Stress, anxiety, and depression were associated with COVID-19-related burden at work, COVID-19-related anxiety, less support at work, and less sense of community. Additionally, stress was negatively associated with age and working in a large care home and positively associated with working in a care home with COVID-19 cases among residents. Though we hypothesized that working in a large care home may be associated with increased psychosocial burden, our results showed the opposite regarding stress symptoms. A possible explanation could be that larger care homes had more possibilities to implement specific hygiene measures, i.e., isolate infected residents, divide areas, and build different `care groups` where only certain nurses would regularly take care of the same residents.

Our study has strengths and limitations. Strengths include a large sample size and detailed, well-validated, and widely used assessments and questionnaires to generate prevalence rates of stress, anxiety, and depression for german nursing staff in care homes. Certain limitations need to be considered. At first, the study sample was recruited online via social media only. Thus, nursing staff with limited access to the internet or web-enabled devices might not have participated in this survey. Further, our study sample was slightly younger with higher qualifications than Germany's usual long-term care workforce [41], raising the issue of selection bias. Both problems may limit generalizability to the entire workforce of nursing staff in german care homes. Moreover, although we took the number of COVID-19 cases into account, our data does not differentiate for regions or COVID-19 hotspots, though there was variation in how much certain areas of Germany were affected by the pandemic. Finally, the retrospective nature of our survey may have biased answers as subsequent events may have influenced the answering of nursing staff.

In summary, high psychosocial burden among nursing staff in care homes in Germany has been shown. These results add new information into the understudied area of care home staff burden and the COVID-19 pandemic. The results could yield strategies that needed to be addressed to help and support nursing staff during a crisis and beyond. Regular psychosocial counseling and programs for the prevention of mental illnesses could be a strategy to buffer the high demands of the nursing job and to prevent the worsening of already existing distress symptoms. Furthermore, social support and a sense of community are essential to cope with an extraordinary circumstance like the pandemic. Regular team meetings, counseling with the care home management, and involving staff in decision-making processes could help strengthen the bond between staff and management and buffer future crises.