An online survey was administered between March and May 2021 to nursing home professionals, namely nurses, professional staff members, managers, and direct care workers. The representative sample comprises 458 professionals: 25 nurses, 287 professional staff members (social workers, psychologists, sociocultural activities coordinators, and others), 67 managers, and 79 direct care workers (responsible for providing bodily care to residents). Respondents’ average age was 41 years, 96% were Portuguese, 73% were women, and 54% were married.

Levels of education varied according to professional role, from basic education (5%) to postgraduate education (35%).

One third of respondents reported having had covid-19, with two thirds of these indicating that they had been infected while working in the nursing home.

National and international institutions have issued guidelines for the infection prevention and control (IPC) of covid-19 in nursing homes. Around 70% of respondents reported that they applied and/or promoted IPC measures before the pandemic (nurses 68%, professional staff members 60%, managers 76%, direct care workers 76%). All respondents reported that the nursing homes where they worked applied the covid-19 IPC measures, with particular emphasis on handwashing, personal protective equipment (PPE), respiratory etiquette and the disinfection of surfaces.

Respondents reported that the most difficult IPC measures to implement were residents placement so as to minimise contact, using PPE and disinfecting used equipment. Nurses reported more difficulties than other professionals, possibly due to their direct responsibility in implementing the measures. 

Respondents considered training to be the most important factor to improve compliance with IPC measures. Although most IPC training was online, it was more frequent and covered a broader range of topics than before the pandemic.

Over 80% of respondents plan to maintain the new IPC measures after the pandemic, as a way of increasing overall safety.

IPC measures implemented during the pandemic, particularly physical distancing, and the mandatory use of masks, changed the way nursing home residents, nurses, professional staff and direct care workers interacted, especially hindering oral communication and the perception of facial expressions. 77% of respondents reported that they had to repeat themselves and 61% reported that they had to ask their interlocutors to repeat themselves and/or use shorter sentences. Only 15% of respondents reported that these measures have hindered the quality of care provided to the residents.

Nursing home managers’ perspective also shows differences in communication before and during the pandemic. According to these respondents, the frequency of communication between managers and professional staff has increased during the pandemic and maintained its quality. Managers reported that the quality of interaction with people outside the institution (i.e., relatives of residents) had deteriorated during the pandemic, even though options for non-face-to-face interaction were available.

Respondents’ negative emotions were clustered around a single statistically significant factor, indicating an overall feeling of sadness, discomfort, fear, and anxiety. This measure of negative emotions showed substantial variation across participants, with some reporting a very low level of negative emotions and some reporting a very high level. Negative emotions were experienced occasionally, with the most negative and most positive emotions being experienced less frequently than more neutral emotions. 

When asked how frequently negative emotions were felt, professional staff and managers reported experiencing negative emotions most often, while direct care workers reported experiencing negative emotions the least often. Notably all groups reported experiencing relatively low frequency of negative emotions, which is reflected in the fact that all scores were below the midpoint of the scale (1=never, 5=always).

However, when asked to “state three words that describe your life during the pandemic”, a stronger affective negative memory emerged in all groups of professionals as depicted in the following word cloud. This suggests that, although the average emotional status is not extreme, there were extreme negative events that lingered in their affective memory.

Respondents reported feeling safe frequently, although individual differences were visible. Most noticeable was the highest reported values of feeling safe occurring in direct care workers (around 4 points out of 5), while professional staff and managers reported the lowest subjective feeling of safety (ranging from 3 to 3.5 points out of 5).

Findings show that training, PPE use and working conditions (with the exception of respiratory etiquette), positively predict the feeling of safety among direct care workers. This may be because both PPE use and working conditions are regulated in Portugal and therefore similar for all participants.

All respondents viewed IPC measures as paramount for improving safety and decreasing the risk of infection both before and during the pandemic.

Direct care workers were most affected by changes in working conditions, with an increased number of working hours (more than 7 extra hours/week) and number of rotating shifts. Consecutive shifts of 12 or more hours and overnight shifts, sometimes without rest, also contributed to that negative impact. More than half of the direct care workers (55%) reported that their personal lives had been impacted, in the sense that they had made changes in the family sphere (not sharing meals or rooms) or in public (avoiding spaces such as supermarkets). They also reported avoiding expressions of affection (hugs and kisses) and social interactions (visits to relatives or friends). Interestingly, although direct care workers faced greater difficulties and risks on the job than the other professional roles, a similar proportion of managers reported disruptions to their personal lives (50%) and a much larger proportion of professional staff mentioned such disruptions (68%).

Managers needed to hire, on average, six new staff members, mainly direct care workers. However, they faced setbacks in the hiring process such as a shortage of applicants, poor qualifications and lack of financial resources for hiring. Regarding applicants, unattractive conditions and fear of infection were the main reasons for declining the offers.

Results from the survey are aligned with other studies that also show difficult working conditions in nursing homes and a shortage of direct care workers. Portugal has the lowest concentration of direct care workers in Europe, with less than 1 worker per 100 people over age 65 (Norway and Sweden have 12.8 and 12.4, respectively). The pandemic is likely to have worsened this ratio.

One limitation is the low number of responses from some socio-professional groups, namely nurses, which could have skewed the results. Additionally, when measuring discrete emotions based on a scale, the true magnitude of the emotional experience may be mitigated as suggested by the stronger presence of negative emotions in the open-ended word cloud.

The covid-19 pandemic has affected nursing home professionals in both their professional and personal lives. Direct care workers have been the most affected in terms of working conditions, but they were the least likely to report frequent negative emotions and fear. IPC measures were decisive, and most respondents plan to keep them after the pandemic is over.

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