As in other countries, German long-term care facilities were and are particularly affected by the COVID-19 pandemic. In our multi-centre interview studies with nursing home and ward managers from different regions throughout Germany, we found six themes each for challenges and strategies for organisational and direct care levels and five themes at the level of consequences. Concerning challenges and strategies for the organisational level, especially appointing a multi-professional crisis task force was one strategy to address federal requirements as e.g. the continuous adaption and implementation of hygiene plans, as also reported by Giri, Chenn and Romero‑Ortuno [16]. This study also reported about basing necessary decisions on evidence or on expert opinions and also about reorganizing the use of building and spatial structures like isolation and cohorting or visiting restrictions [16].
Especially reduced staffing levels have been described as a challenge in managing the pandemic [17]. To overcome this challenge our study indicated the use of different strategies in adapting staff deployment to dynamically changing demands, such as changed routines or shift equalizing. Also refraining from recruiting loan workers to avoid an increased risk of infection outbreaks in the nursing homes has been reported from other countries [18]. Increased payments and incentives for staff have been reported to reduce staff shortages [16], but were not applied in Germany.
The theme managing additional communicative demands was not directly reported in other studies, but is described as one elementary strategy to overcome other challenges, especially related to convey information about adapted federal regulations and to avoid misinformation. This might be due to the fact that nursing home managers in Germany are usually close to nursing practice and it is not uncommon for them to take over nursing duties if necessary. Other studies also report inconsistent messaging about restrictions by authorities, which led to several problems and to a prioritisation of quantity instead of quality of life which included ongoing social isolation [19]. Staff in nursing homes had to deliver care in a pandemic context and to make existential decisions. To be informed, they used external networks, but criticized multiple, sometimes contradicting, sources of expertise and information and also a lack of prioritisation by authorities which led to additional work and sometimes impaired the ability of staff and managers to make decisions [20].
Also, the relying on and resorting to informal networks was described in the literature in relation to adapt given restrictions by local initiatives [16]. A resource was dedicated and inventive staff and the using of existing local networks [21]. In our results, informal networks were mostly used as a strategy in securing material procurement and the use of building local networks in nursing was described as a future strategy to overcome situations like this in Germany.
At the direct care level changed routines with the measure to isolate residents in their rooms, especially in meal times, was reported in our study, which was also described in other studies e.g. as an influencing factor for malnutrition [22]. Other described changed routines focussed structural strategies like a changed handover structure or infection control measures. Especially these led to increased documentation demands as e.g. the need to document daily symptoms and parameters for residents and staff and also access of visitors after the easing of restrictions.
Another challenge described in our study and mainly responsible for changed routines was taking over of non-nursing tasks. In the US one reported counter-strategy was to involve the public as volunteers [23], but the German restrictions did not allow this within the general ban on access. Thus, against the background of understaffing in nursing, German nurses had to take over measures such as physical activity, chiropody or hairdressing.
Especially, social isolation led to a huge workload in promoting social participation for the residents to avoid negative consequences. Reduced social interaction between residents as well as between staff and residents, and lower levels of physical activity led to physical decline in some residents [16]. Especially people with dementia showed some negative psychological and cognitive effects due to the imposed restrictions, such as increased apathy, irritability, or anxiety, which were fuelled by lack of social activities. Therefore keeping residents to simple routines that included leaving the home for exercise and stimulation should have been prioritised by staff [24], but could not be performed due to the restrictions and the increased workload. These influencing factors led to a feeling of social isolation. To address these challenges the German Society for Nursing Science published a guideline to prevent social isolation in nursing homes under pandemic conditions [25], aiming to promote self-determination and quality of life, even under pandemic conditions. Wearable devices or robotic support have been described as an opinion to support nurses in promoting social participation [16], but these are not common in German nursing homes. To avoid a general decline in psychological well-being and cognition, creative support measures for residents like increased walking, window or behind-glass visits and video calls were used as also described in the literature [26].
For residents with severe care dependency and residents with dementia, individual care is often of social interaction and protection from loneliness. Wearing protective equipment can be a hindrance to this. Increased communication demands also concerning ongoing psychosocial individual conversations with residents and their relatives were another challenge mentioned in our interviews. Understanding necessary physical distancing measures and correct utilisation of personal protective equipment may be limited in nursing home residents with dementia, which has been described as a potential risk to COVID-19 spread in some nursing homes [23].
During the pandemic, other complaints were sometimes neglected, trivialised or concealed by residents for fear of inpatient hospital treatment. This could have led to a delayed start of diagnosis and therapy with sometimes severe consequences [27]. The dimension of the outbreaks and the high lethality among residents led to massive restrictions, especially in the area of social contacts and activities, but also in areas of medical care, which led to an increased medical responsibility for nurses, which has also been associated with negative emotional consequences. According to one study, monitoring residents’ vital signs via telehealth was feasible, but this was not available in most nursing homes [28]. In particular, increased medical responsibility that comes with an increase in overall responsibility was described to contribute importantly to nurses’ workload. The scoping review of Giri, Chenn and Romero-Ortuno did not report this for any other study. A likely reason for this could be that there are hardly any nurses with bachelor degrees working in German nursing homes. In addition, the comparatively unfavourable staff-to-resident ratio and the high number of untrained staff in German nursing homes supports this theory. Especially the staff-to-resident ratio has been described as an influencing factor associated with excess COVID-19 transmission and mortality in nursing homes [16].
Beside the themes for challenges and strategies, we found positive and negative themes at the level of consequences. These are positive emotional consequences for nursing home managers and staff who described resources for these challenges, psychological stress for all facility employees and negative emotional consequences, especially focussing a permanent feeling of responsibility and an increased potential for conflicts. Most of these consequences are not described directly in other studies, which could be explained by the specific conditions of the German nursing and health-care system.
The positive emotional consequences for nursing home managers and staff were described as a feeling of a newly established team cohesion, a feeling of a calm atmosphere because of the general ban on visits, a stronger sense of connection between nursing staff and residents, but also ongoing with a symbiotic bond feeling. As resources for these challenges, the support of the team by nursing home and ward managers, stalled quality checks by federal institutions and care level classifications by the health insurances were mentioned.
The psychological stress for all facility employees was caused by the increased effort for all tasks due to the imposed restrictions, which led to an increase in internal (with staff and residents) and external (with relatives and other external institutions) communication efforts with an increase in possible conflicts. Especially infection control requirements led to a huge need for clarifying discussions. A lack of transparency and accuracy in the transmission of information by the federal government was mentioned as an influencing factor for psychological stress and led to a feeling of uncertainty.
The negative emotional consequences were described as a feeling of lack of support from federal institutions and a feeling of fear because of the lack of protective equipment. Dissatisfaction and anxiety among nursing home staff, like financial, psychological, and work-related stressors, have also been described in other studies [16]. The uncertainty during the pandemic with no experiences from the past and a lack of clear instructions was also associated with negative emotional consequences, with the possibility of a tradition of low policy priority for the long-term care sector. Specific and clear guidelines could be one possible strategy to counteract staff anxiety in relation to this topic [16].
Beside this challenge, in particular the permanent feeling of responsibility led to a feeling of a too great sense of responsibility in combination with fear of serious errors in medical care, which has also been described in other studies, especially for nursing home residents with specific comorbidities [29]. The increased potential for conflicts due to demanding communication with residents´ relatives was another influencing factor for the perceived stress level of staff in German nursing homes.
Strengths and limitations
Although our study is based on a comprehensive sample of qualitative date from 43 nursing homes from Germany, some limitations have to be acknowledged. First, results are limited to the first wave of the COVID-19 pandemic. Second, the convenience sample of institutions with an affinity for studies increases the possibility of answers influenced by social desirability. Another possible limitation could be researchers’ focus on relevant data material only. Therefore, we confronted the analysers with alternative interpretations through peer group reflection to establish consensual validation and intersubjectivity.
The strengths of our study are the large sample of nursing homes in different regions in Germany and the data collection in a timely manner in the first wave of the pandemic. Therefore, the results are transferable and generalizable for the German healthcare system.