EXPERIENCES OF PROVIDERS OF CARE FOR INSTITUTIONALIZED ELDERLY PEOPLE DURING THE COVID-19 PANDEMIC: A QUALITATIVE PERSPECTIVE

ABSTRACT

Objective:

Uncover the experiences of caregivers of elderly people living in long-term care institutions, during confinement in the context of the Covid-19 pandemic.

Method:

Qualitative, descriptive research, through an intrinsic case study. Intentional sample by criteria and convenience of six caregivers, Los Ríos Region, Chile; a semi-structured interview was carried out in 2021. Analysis applying the constant comparative method and progressive focusing approach. Validity was ensured by compliance with the criteria of rigor and researcher triangulation.

Results:

489 units of meaning gave rise to four thematic groups: Meaning of having lived the experience, facilitating factors, hindering factors and recommendations. Two domains emerged: Contribution of caregivers to strengthening their role during the pandemic and Contribution to strengthening management. Conclusions: it allows recognizing and validating the emotional bond, commitment and vocation of care providers, key aspects to be reinforced through counseling and training to guarantee the quality of care.

KEYWORDS:
Long-term care institution for the elderly; Caregivers; Pandemic; Psychological stress.

RESUMO

Objetivo:

Desvelar as vivências de cuidadores de idosos que residem em instituições de longa permanência, durante o confinamento no contexto da pandemia de Covid-19.

Método:

Método: pesquisa qualitativa, descritiva, através de estudo de caso intrínseco. Amostra intencionada por critério e conveniência de seis cuidadores, Região de Los Ríos, Chile, entrevista semiestruturada foi realizada no ano de 2021. Análise através de comparação constante e redução progressiva. A validade foi garantida pelo cumprimento de critérios de rigor, triangulação por especialistas.

Resultados:

489 unidades de significado deram origem a quatro grupos temáticos: Significado de ter vivido a experiência, fatores facilitadores, fatores dificultadores e recomendações. Emergiram dois domínios: Contribuição dos cuidadores para o reforço do seu papel durante a pandemia e Contribuição para o reforço da gestão. Conclusões: permite reconhecer e validar o vínculo afetivo, o empenho e a vocação dos prestadores de cuidados, aspectos fundamentais a reforçar através do aconselhamento e da formação para garantir a qualidade dos cuidados.

Palavras chave:
Instituicão de Longa Permanência para Idosos; Cuidadores; Pandemia; Estresse Psicológico.

RESUMEN

Objetivo:

develar las vivencias de cuidadores de personas mayores que residen en instituciones de larga permanencia, durante el confinamiento en contexto de pandemia por Covid-19.

Método:

investigación cualitativa, descriptiva, mediante estudio intrínseco de casos. Muestra intencionada por criterios y conveniencia de seis cuidadoras, Región de Los Ríos, Chile, se realizó entrevista semiestructurada, en el año 2021. Análisis a través de comparación constante y reducción progresiva. Se cauteló validez cumpliendo criterios de rigor, triangulación por expertos.

Resultados:

489 unidades de significado originaron cuatro núcleos temáticos: Significado de haber vivido la experiencia, factores facilitadores del trabajo, factores que lo dificultan y recomendaciones. Emergieron dos dominios: Aportes de las cuidadoras para fortalecer su rol durante la pandemia y Contribución para fortalecer la gestión. Conclusiones: permite reconocer y validar el vínculo afectivo, compromiso y vocación de las cuidadoras, aspectos fundamentales a fortalecer mediante consejería y capacitación para asegurar la calidad de los cuidados.

Palabras clave:
Hogares para ancianos; Cuidadores; Pandemia; Estrés psicológico.

HIGHLIGHTS

1. Qualitative aspects of the care provided to elderly people institutionalized during the pandemic.

2. Development of emotional connection: compassion as a protective factor in the face of adversity.

3. Caring for caregivers of elderly persons: empathy, commitment and respect.

4. Factors that facilitate care in a pandemic situation.

HIGHLIGHTS

1. Qualitative aspects of the care provided to elderly people institutionalized during the pandemic.

2. Development of emotional connection: compassion as a protective factor in the face of adversity.

3. Caring for caregivers of elderly persons: empathy, commitment and respect.

4. Factors that facilitate care in a pandemic situation.

INTRODUCTION

The elderly constitute one of the most vulnerable groups to infection and death from COVID-19, and it is estimated that the probability of severity in the population over 80 years of age is five times higher than that of the general population¹. This reality has become a challenge in long-term care facilities for the elderly, as they have been widely affected by COVID-19, accounting for 40% to 88% of COVID-19 deaths worldwide²-³. This scenario required optimization and modification of risk management by health institutions, taking the measure of confinement of the elderly to extremes, and caregivers play an important role in this context⁴. It should be noted that there are 947 long-term care institutions (1.5% public, 22.5% non-profit and 75.9% private) in Chile, which provide care to 23,600 elderly people⁵.

Studies carried out before the pandemic show that the quality of life perceived by caregivers in nursing homes is influenced by the work overload experienced by the type of care to be provided, as most residents are dependent and require greater physical effort in the care provided to them and consequently greater demands on caregivers’ tasks. Working conditions such as working hours, the number of residents under the care of a caregiver and the fear of contamination must also be considered⁶-⁷.

In the health context associated with COVID-19, caregivers in long-term care facilities did not initially feel prepared to adapt to changes in work associated with preventive measures. This generated a high level of stress for these professionals due to the high risk associated with their activities during the pandemic⁷-⁸. Furthermore, physical discomfort and problems falling asleep were observed, which affected routine activities, with an impact not only on professional performance, but also on relationships with family and friends, leisure activities and free time, as well as intimacy. However, people’s perception of the role of caregivers depends on the interaction between the physical, psychological and social burden in their lives⁹-¹⁰.

The threat to the harmony of their relationships can lead the caregivers to become apathetic and indifferent towards the persons that are cared for, and depersonalized treatment is provided. Furthermore, the strong feeling of overload can become a risk factor for physical and psychological assault or for voluntary and involuntary neglect, lack of protection and physical care, such as neglect of nutrition, poor response to emotional needs and cognitive stimulation of elderly people, which results in abandonment and the caregiver’s inability to care for the elderly person ¹¹-¹². This situation is known as severe caregiver burden, which affects their quality of life and, consequently, the care provided¹³.

Healthy habits, such as regular sleep-wake cycle, healthy diet, regular physical activity, rest periods and self-care, are considered factors that facilitate and protect the health of caregivers. This allows them to maintain greater well-being, optimal functioning and improve their health, generating less subjective burden and greater resistance to stress and negative effects¹⁴.

Coping strategies and social support are factors that can influence, buffer or mitigate the emotional burden and discomfort of caregivers¹⁵. Furthermore, training in technical and relational areas could reduce problems between peers and with the institution’s management, as these are important factors of chronic work stress¹⁶.

To provide quality care to elderly people, caregivers must possess certain skills, such as awareness and emotional regulation, positive attitudes and social skills, patience and empathy towards the individuals they care for. However, in the dynamics of interaction with co-workers, it became clear that there are difficulties in putting into practice skills such as emotional self-regulation, positive attitudes, negotiation and active listening, which can generate conflicts¹⁷.

As has been discussed with health professionals on this topic, an emotional bond is generated between the caregiver and the elderly person, which increases over time, and which is crucial for the quality of care provided; on the other hand, proactive self-care and self-compassion support and increase the ability of caregivers to manage emotions and prevent negative consequences that result from tiredness and fatigue¹⁸.

There is evidence of worsening of the physical and psychological health of caregivers due to the increased care burden, which harms the relationship with the people cared for, increasing the risk of abuse¹⁹. Caregivers give meaning to their work, making it possible to identify reciprocity, love and compassion (relationship between subjects), give their best and take on the life of the person being cared for (preservation of existence, responsibility), take care of the needs of others, situations that the other cannot resolve alone (service), a strong commitment, also called vocation (meaning of life), solidarity, compassion and recognition of the other (love)²⁰_.

The pandemic context and scenario lead us to reflect on the health of those responsible for providing care to institutionalized elderly people and the underlying qualitative aspects, taking into account the demands of this practice, associated with personal and family factors determined by the context of confinement.

With the purpose of investigating, based on a holistic perspective of formal caregivers, in a local context that provides relevant information to be considered in future assessments of these health actors, the researchers set out to discover the experiences of caregivers of elderly people who lived in residences for the elderly in the Los Ríos Region, Chile, during confinement in the context of the Covid-19 pandemic.

METHOD

Research based on qualitative, exploratory, descriptive, interpretive methodology, using an intrinsic case study²¹. Given the nature of the study, which aims to understand the phenomenon and not generalize the results, an intentional sample of cases was used by criterion and convenience, whose inclusion criteria were as follows: professional who has being working as a formal caregiver for more than five uninterrupted years, hired by a long-term care institution for the elderly in the Los Ríos Region, Chile and with Internet access. The sample consisted of six participants out of 10, all women, and the number of informants was determined by data saturation, that is, when no new data emerged. The professionals were invited by telephone to participate in the study. After accepting the invitation, they received the free and informed consent form by email, their doubts were clarified and the answers were subsequently forwarded to them. Each of the participants received an identification number and the documents were kept in a folder specially prepared for this purpose.

The data were collected by one of the researchers, with experience in this type of study, and who had no connection with the participants. Collection was carried out during the second half of 2021 (from August to October) through a semi-structured interview, based on a route guide (the questions were elaborated by the researchers in accordance with the objective of the study); the time was defined based on the availability of each participant, online, through the Zoom²¹ platform. The interviews were recorded and transcribed verbatim, with prior authorization, to guarantee methodological rigor. The participants did not receive any remuneration and had access to the transcript of their interviews. Data transcription was carried out by two researchers.

The constant comparative method of Glaser and Strauss (1997)²² was used in data analysis. Thus, data was not grouped into pre-determined categories, emerging from an inductive process, through a method that generates and constructs categories where inductive coding of categories was combined with the constant comparison of them. It was carried out manually by three researchers, using the scheme proposed by Miles and Huberman²³, with progressive reduction (separation of units, grouping, identification and classification of elements), arrangement, transformation and obtaining verifiable conclusions. The progressive level of reduction and theoretical structuring was divided into three levels²².

Level 1: Segmentation of units of meaning by thematic criteria

Level 2: Construction of a system of emerging thematic cores or metacategories based on the units obtained at the first level.

Level 3: Identification of qualitative domains based on sequential and transversal analysis of metacategories.

It should be noted that the process of analysis was concomitant with data collection, systematic, orderly and flexible, reflecting in a certain way the holistic nature of qualitative research, and the data was triangulated by the researchers and shared with the participants.

Reliability was ensured using the rigor criteria determined by veracity strategies: truth-value or credibility; dependability or consistency, applicability or transferability; and neutrality or confirmability²⁴.

The study met the seven requirements of research ethics ²⁵: Social value, scientific validity; equitable selection of subjects; favorable risk-benefit ratio; independent assessment; respect for subjects and confidentiality of information. The study was approved by the Scientific Ethics Committee of the Valdivia Health Service, under Protocol No. 377, of 11/30/2020. The data were stored on the main researcher’s personal computer, to which only she has access, and the participants’ names were replaced with fictitious names.

RESULTS

At level 1, 484 units of meaning were identified, forming 4 descriptive categories coded according to the study objectives: Experiences as caregivers of elderly persons in long-term care institutions during confinement in the context of the Covid-19 pandemic; Factors that facilitate the role of caregivers of elderly people in long-term care institutions during confinement in the context of the Covid-19 pandemic; Factors that hinder the role of caregivers of elderly people in long-term care institutions during confinement in the context of the Covid-19 pandemic; Recommendations for those who work with elderly people in long-term care institutions, each of them represented by the tables presented below, which contain the frequencies of the units of meaning emanating from the speeches (Tables 1 to 4).

Table 1
Frequency distribution of units of meaning in the category: Experiences as caregivers of elderly people in long-term care institutions during confinement in the context of the Covid-19 pandemic. Valdivia, Chile, 2021

Coded descriptive categories	Units of meaning	Frequency of units of meaning
		n	%
Psychological Aspects	Stressful	14	11.6
	Concern	13	10.8
	Emotional exhaustion	11	9,2
	Bad mood	5	4.2
	Demanding	3	2.5
	Social isolation	3	2.5
	Lack of leisure	2	1.7
Physical Aspects	Fatigue	6	5.0
	Reduced physical activity	2	1.7
Safety and hygiene	Personal protection measures	5	4.2
	Existence of protocols	3	2.5
Employers	Training	4	3.3
	Commitment	4	3.3
Elderly perception	Family isolation	19	15.9
	Anxious	6	5.0
	Physical dependence	5	4.2
	Demanding	4	3.3
	Sad	4	3.3
	Emotional needs	4	3.3
	They are people who think and feel	3	2.5
		120	100

Source: The authors (2021).

Table 2
Frequency distribution of units of meaning in the category: Factors that facilitate the role of caregivers of elderly persons in long-term care institutions during confinement in the context of the Covid-19 pandemic. Valdivia, Chile, 2021

Coded descriptive categories	Units of meaning	Frequency of units of meaning
		n	%
Personal Qualities	Respect	20	12.2
	Empathy	15	9.2
	Vocation of service	15	9.2
	Patience	13	8.0
	Expression of affection	11	6.7
	Sensitivity	10	6.1
	Tolerance	8	4.9
	Resilience	6	3.7
	Optimism	6	3.7
	Joy	6	3.7
	Willpower	5	3.0
	Altruism	5	3.0
	Separate personal and professional life	4	2.4
	Experience	3	1.8
	Effective communication	3	1.8
	Willingness to learn	3	1.8
	Knowledge	2	1.2
Professional skills	Skills for working with elderly people	7	4.3
	Working with peers	3	1.8
	Proactivity	2	1.2
	Coordination of actions	2	1.2
Resources	Support to the family	5	3.0
	Availability of leisure spaces	4	2.4
	Practice self-care activities	4	2.4
	Training	2	1.2
		166	100

Source: The authors (2021)

Table 3
Frequency distribution of the category’s units of meaning: Factors that hinder the role of caregivers of elderly persons in long-term care institutions during confinement in the context of the Covid-19 pandemic. Valdivia, Chile, 2021

Coded descriptive categories	Units of meaning	Frequency of units of meaning
		n	%
Personal qualities	Sleeping outdoors	13	17.5
	Disruption of family dynamics	10	13.5
	Fear	4	5.4
	Need for help from others	3	4.1
	Social isolation	3	4.1
	Lack of leisure	3	4.1
	Study and work	1	1.3
Labor aspects	Fatigue from having to teach new employees	7	9.4
	New staff with insufficient skills	6	8.1
	Lack of transportation to the workplace	6	8.1
	Limited physical contact with PM	6	8.1
	Staff turnover	4	4.1
	Lack of training	3	5.4
	Work overload	3	4.1
	Adapting to working with PPE	2	2.7
		74	100

Source: The authors (2021)

Table 4
Frequency distribution of the units of meaning of the category: Recommendations for those who work with the elderly in long-term care institutions. Valdivia, Chile, 2021

Coded descriptive categories	Units of meaning	Frequency of units of meaning
		n	%
Personal domain	Respect	20	16.2
	Empathy	13	10.5
	Patience	12	9.8
	Vocation of service	7	5.6
	Compassion	6	4.8
	Expression of affection	6	4.8
	Assertiveness	5	4.0
	Self-care	4	3.2
	Tolerance	3	2.4
	Availability	3	2.4
	Good nature	3	2.4
	Separate personal and professional life	2	1.6
	Proactivity	2	1.6
Labor domain	Staff training	17	13.7
	Implement recreational activities	8	6.5
	Manage staff recruitment in a timely manner	6	4.8
	Incentives	5	4.0
	Group work	2	1.6
		124	100

Source: The authors (2021)

Level 2 describes the emerging thematic cores or metacategories that arise from the 4 coded descriptive categories that emerged in level 1. An inter-category comparison was then made in which structural similarities and common elements were sought in this analysis, resulting in 3 thematic cores or metacategories that represent the reality investigated as described by the key informants.

Metacategory 1: Contribution of caregivers of elderly people related to their experience of performing their role during the pandemic. Defined as views related to psychological and physical aspects, perception of older people, health and safety, and employers, derived from their role as providers of care for older people during the pandemic.

Metacategory 2: Components associated with factors that impact the performance of caregivers of elderly people during the pandemic. It refers to the appreciation of aspects that contribute to (personal qualities, skills and resources for work) and make it difficult for them to perform their role (personal and labor aspects) as caregivers of elderly people during the pandemic.

Metacategory 3: Suggestions from caregivers of elderly people to optimize their work regardless of the pandemic. It corresponds to the assessment of caregivers regarding aspects of the personal and work environment that would contribute to improving the performance of their role in long-term care institutions.

Level 3 corresponds to sequential and transversal analysis of the metacategories, giving rise to two qualitative domains, derived from the negotiation of meanings and interpretations carried out together with the researchers (Table 6).

Figure 1
Definition of domains. Valdivia, Chile, 2021

DISCUSSION

In line with the objective of this study, which is to uncover the experiences of caregivers of elderly people living in long-term care institutions during confinement in the context of the Covid-19 pandemic, the informants’ revelations are consistent with the literature findings.

Regarding target metacategory 1, which encompasses the descriptive categories “Psychological Aspects”, “Physical Aspects” and “Safety and Hygiene”, in the first of them, the experience was exhausting and demanding, marked by the possibility of affecting residents. As in other studies, concern, emotional exhaustion, social isolation and lack of leisure resulting from working with elderly people in a risk context had an impact on interpersonal relationships8^-10.

This experience was exhausting and made it impossible to maintain practices related to routine physical activity, constituting the descriptive category “Physical Aspects”, whose repercussions on physical and psychological health are associated with the increased burden of care¹⁹. In addition to the above, the descriptive category “Safety and hygiene” emerges, which refers to personal protection measures and the existence of protocols that have been implemented for immediate care for the elderly. However, they confirm that at the beginning of the pandemic, caregivers did not feel prepared, despite the training provided in the institutions⁷.

Regarding the descriptive metacategory “Perception of the elderly”, caregivers are valued by residents in vulnerable situations, due to the isolation in which they find themselves, which causes them anxiety and helplessness and physical dependence. The results are in line with the literature, implying a higher level of demand for caregivers⁶-⁷.

Regarding the descriptive metacategory “personal domain”, some caregivers lived outside the city, and therefore, due to the lack of transport, they had to adapt their dynamics and restrict travel to their homes, which caused changes in family dynamics, with an impact also on an emotional level. From the point of view of “work”, caregivers stressed their tiredness because they had to constantly teach new employees, as there was a high turnover of new employees, and they lacked many skills to carry out their work, and also due to the impossibility of physical contact with residents to avoid contamination. This caused frustrations among caregivers, because many of the activities carried out before the pandemic and that generated well-being for both residents and caregivers could no longer be carried out. The results obtained for hindering factors are in line with the experiences of elderly care providers in long-term care facilities during the pandemic with regard to “physical appearance” and “safety and hygiene”¹¹-¹³.

Regarding the facilitating factors that allowed caregivers to provide care during this period, contrary to findings in the literature, despite the heavy workload, it can be seen that the caregivers interviewed were always emotionally connected to the residents and very concerned about their emotional needs¹¹-¹³. This can be attributed to the units of meaning of the descriptive category “personal qualities”, which are directly related to the ability to care for others, highlighting respect, empathy, the vocation of service, patience, the ability to express affection, sensitivity, among others¹⁷.

Likewise, they also recognize “work skills”, particularly the skills to work with elderly people, which in this case may be linked to their several years of experience, added to the desire to learn and knowledge, which would facilitate training of caregivers by the institution, with the ultimate objective of avoiding overload on these professionals¹⁶. In the descriptive category “Resources”, from a personal point of view, family support, the availability of leisure spaces and the practice of self-care activities are of great importance, the latter coinciding with what has been reported in other studies¹⁴-¹⁵.

It is worth mentioning that recommendations emerged in the statements (metacategory 3) in the descriptive categories of “Personal Domain” and “Labor Domain”. The first are related to “Personal Qualities” revealed in the factors that facilitate the role of caregivers, while the second, where staff training and the implementation of recreational activities are identified, is related to what has been suggested by other authors¹⁵-¹⁶.

It should be said that this study allowed us to understand that the experience of caregivers during confinement was closely associated with their affection and commitments to the people they care for. This can be attributed to the meaning they give to their work, and is a source of motivation, which awakens compassion in them when they see residents in a vulnerable situation because they are separated from their families, physically and emotionally dependent. This bond was referred to by another author as a protective aspect to prevent negative effects and manage emotions¹⁸,²⁰.

Regarding the limitations of the study, access to the participants was difficult, due to their heavy workload and multiple responsibilities arising from the context of confinement. However, after the interviews, the respondents expressed their gratitude for this opportunity to express their feelings and emotions.

FINAL CONSIDERATIONS

According to the results obtained, it can be concluded that the development of emotional attachment and compassion in caregivers is a protective factor against adverse scenarios that can affect the dynamics of care. Despite the high demands of the role of caregiver in pandemic times, the physical demands associated with the workload and the psychological stress resulting from this context, a strong commitment to the elderly, empathy with their needs, attempt to maintain contact with them and, above all, respect for them as human beings prevailed among caregivers.

As for contributions to professional practice, we can recognize and validate the emotional bond, commitment and vocation of caregivers to care for the elderly. From the point of view of professional practice, this should be one of the pillars to be reinforced by nursing, through counseling and training to guarantee the quality of care.

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Edited by

Associate editor: Dra. Luciana Kalinke

Publication Dates

• Publication in this collection
  27 Nov 2023
• Date of issue
  2023

History

• Received
  31 May 2023
• Accepted
  17 Aug 2023