Listen to the voices of nurses: the role of community chief nurses and registered nurses in the provision of care for older people in Sweden during the COVID-19 pandemic – a cross-sectional study

The study has a mixed method cross-sectional design consisting of questionnaires with close- and open-ended questions targeting CCNs and RNs working in the care of older people.

The checklist of guidelines for cross-sectional design, STROBE (EQUATOR) research reporting checklists have been uploaded).

Inclusion criteria for the participants were as follows: RNs or CCNs who had been working in the municipal care of older people during the first wave of the COVID-19 pandemic in Sweden in the spring of 2020, which included RCFs as well as home care.

The data collection involved the employment of two questionnaires, one developed for CCNs and one for RNs. They focused on these areas: Prerequisites for the prevention of the spread of the virus; Support for RNs and staff, Prerequisites for the provision of good medical and nursing care and demographic data. The questionnaire for the CCNs had five questions, of which four included an open-ended response. The questionnaire for the RNs had 16 questions, of which nine included an open-ended response. Three questions were the same in both questionnaires, and the remaining questions were more specific in terms of the roles and responsibilities the respondents had as CCNs and RNs: see the Appendix.

Questions pertaining to infection control and management of individuals infected with COVID-19 were derived from those used by the Swedish Public Health Authority. The remaining questions, developed by the authors specifically for this study, focused on the roles of CCNs and RNs as well as care provision during this period. Additionally, demographic data, including educational levels, years of experience as an RN, and time spent in their current role, were collected. RNs with PhD and involved in research of the care of older people, as well as and representatives from Swedish Society of Nursing (SSN) read the questions and response alternatives to check the readability and clearness of the items. Given the urgency of the pandemic, we deemed it necessary to conduct data collection promptly, precluding any additional testing of the formulated questions, no further testing of the developed questions was made.

The participants were recruited via SSN, which sent out an invitation and a link to the questionnaire to all their members to take part in the study in their monthly newsletter and in social media. The questionnaires were open for responses from the beginning of June 2020 until the end of August 2020. Respondents could access the link to the electronic questionnaires that was published on the SSN website.

The two questions that relate to whether it was possible to provide good medical care and nursing care reported by the RNs were chosen as dependent variables for the regression analyses (Table 1). The independent variables were identified from the three categories as Prerequisites for the prevention of the spread of the virus; Support for RNs and staff; and Prerequisites for the provision of good medical and nursing care (Table 1).

According to Swedish law, studies that do not involve sensitive data, such as data relating to health, politics or sexual orientation, do not require permission from the Ethical Review Authority (Ethical Review Act 2003:460, https://​www.​onep.​se/​media/​2348/​the_​ethical_​review_​act.​pdf ). This study was conducted in accordance with the ethical standards as set in the Declaration of Helsinki and its later amendments [25]. The respondents were given information about the purpose of the study and were told that participation was voluntary and that their answers were anonymous. By filling in the questionnaire, the informant gave their informed consent to participate in the study. They were also told that the results would be presented in a way that would prevent the identification of the respondents.

The questionnaires were answered by 208 CCNs and 925 RNs. The CCNs had on average 25 years of experience as RNs, and an average of six years as CCNs. Just over two thirds were specialised nurses at the master level whose main focus areas were the care of older people, primary healthcare and psychiatric care.

Of the 925 RNs, 14 did not work in the care of older people; for this reason, they were excluded, which left 909 RNs who met the inclusion criteria. On average, these RNs had worked 10 years in RCFs or in home healthcare, and 319 (35%) had specialized nursing training at the level of master; of those, 117 (13%) were specialised in the care of older people and 113 (10%) in psychiatric care, midwifery, anaesthesia or pre-medicine.

About half of the RNs reported receiving support in their role during the pandemic from a CCN (22% always and 35% to a high extent) (Table 4). Two thirds of the RNs (28% always and 43% to a high extent) reported receiving support from their frontline manager. About two thirds of RNs reported that their manager was an RN. The remaining RNs reported that their frontline managers were professionals such as sociologists, occupational therapists, physiotherapists and assistant nurses. About 15% of RNs did not report the profession of their manager. The RNs who reported that their frontline manager was an RN also reported receiving support from their manager to a higher extent than those whose manager was not an RN by profession (76% compared with 63%; p<0.001).

More than half (58%) of the RNs reported that during the pandemic, recurring meetings were held to discuss the ethical issues of COVID-19. Meetings for reflection between RNs and staff were arranged as well as for RNs solely. These focused on processing the situation and also on exchanging experiences and improving the care in their units.

The univariate logistic regression models revealed that all independent variables were significantly associated with the two dependent variables except for the independent variable “Recurring occasions when ethical issues have been discussed” (Table 5).

In the multiple logistic regression model with the dependent variable “Ability to provide good medical care”, these four independent variables were significantly associated with the dependent variable: “Competence to care for people with COVID-19” (OR=1.92); “Support from frontline manager” (OR=1.69); “Staff’s ability to comply with hygiene practices” (OR=1.64); and “Physician at bedside assessing people” (OR=1.57).

In the second logistic multiple regression model, these four independent variables were significantly associated with the ability to provide good quality nursing care: “Staff’s ability to comply with hygiene practices” (OR=2.31); “Competence to care for people with COVID-19” (OR=2.09); “Information-sharing with staff” (OR=1.45); and “Physician at bedside assessing people” (OR=1.39).

The two independent variables “Ability to isolate people showing symptoms of COVID-19” and “Support from CCN” were significantly associated with the two dependent variables in the univariate analyses but not in the multiple logistic regression models.

Most CCNs reported that guidelines to prevent the spread of the infection as well as to care for older people with COVID-19 worked well, although some CCNs pointed out problems implementing these guidelines in RCFs and home care. Similar results were found, stating that a lack of guidelines and teamwork regarding hygiene practices resulted in staff developing their own strategies [26]. To a greater extent than the CCNs, the RNs reported that the quality of care, as well as the person’s safety, were negatively affected during the pandemic. RNs reported a greater negative impact on care quality and patient safety during the pandemic compared to CCNs. Johansson-Pajala et al. [27] described heightened anxiety and loneliness among older people in RCFs during the first wave. Additionally, studies from other countries revealed similar findings, such as diminished person-centered care and reduced promotion of dignity for older people [28]. Schrack et al. [29] reported decreased social contact for persons with dementia in RCFs during the pandemic. In addition, Sweeney et al. [30] found similar results, which suggests that the care of older people was affected regardless of whether or not they had COVID-19. The older people who did not have the virus were neglected as a result of staff working under pressure. During the pandemic, failures in care were highlighted in Swedish media, which brought to light the issues in Sweden’s care of older people in the municipalities: some of these issues were inadequate staffing, non-continuity of staff and inadequate competence where it was needed. There was also an issue with the coordination of healthcare regional [4, 21]. Previous research, as well as our results, correspond with the report by the Swedish Corona Commission [21] that showed that the care of older people was majorly affected. Staff lacked the necessary training in how to care for older people, and there were major failures as a result of inadequate care brought about by COVID-19 in relation to such aspects as hygiene practices and end-of-life care.

Previous studies have indicated that a considerable number of care staff working with older people do not have Swedish as their first language [21, 30]. Our results highlighted the consequences of this situation, wherein a considerable portion of staff in RCF have Swedish as their second language. This can lead to communication issues and hinder their full comprehension of guidelines, restrictions, and new practices. This came to light in the corona commission report as well, and the Swedish government has now decided to place resources (about 30 million SEK) on the language (Swedish) training of staff [31]. One third of the RNs reported that staff had difficulties implementing basic hygiene practices. Hanna et al. [19] also found this issue in their study: where the roles of staff rapidly changed and came to include duties that they were not prepared for as they worked to prevent the spread of the virus. Both Sweeney et al. [30] and Hanna et al. [19] found that staff were afraid of spreading the virus to the older people in their care, to their families and to themselves as well, which corresponds to the responses to the open-ended questions in our study.

Our findings revealed that 33% of the RNs reported that a physician was seldom or never present for bedside assessments or treatments. This issue was also highlighted in the report by the Corona Commission [21], which identified a substantial problem stemming from the fact that physicians are employed at the regional level, rather than the municipal or private level. This arrangement proved to be problematic for the organization of care. In our results, the RNs expressed a sense of loneliness in their struggle to provide high quality care for the older persons in their care. Bergqvist et al. [26] shed further light on this from the point of view of staff (nurse assistents), who described their sense of loneliness and of being disregarded as they were often left alone and did not receive adequate support from their managers, RNs and municipality-level management. In addition to this, the report of the Corona Commission [21] pointed out that inadequate staffing and competence resulted in an untenable work situation for both staff and RNs, which negatively affected the care and safety of older people in RCFs and home care during the pandemic. Our study, as well as that by Bergqvist et al. [26], describes a lack of appropriate nursing competence during the pandemic; however, the fact is that even not in the face of a pandemic, there are too few RNs working in the care of older people in Sweden before the pandemic. Only 9% of those employed in the care of older people in Sweden are RNs and as our results demonstrate, they may have responsibility for caring for between 400 and 600 older people during a work shift [32]. This means that it is impossible for them to work bedside, which became even more obvious during the pandemic when the older people needed advanced care.

About one third of the RNs described a lack of support from their managers; in contrast, those whose managers were RNs were to a greater extent satisfied with the support they received. Dissatisfaction with leadership and management has been confirmed by previous national and international research [33‐38]. In Sweden, this may not be surprising, as frontline managers in the care of older people oversee a large group of staff (averaging 42 staff members in home care and 50 staff members in RCFs). Consequently, providing support to each staff member presents a considerable challenge [39]. The report of the Corona Commission describes a need for more advanced care and thus higher nursing and medical competences: these aspects were made apparent during the pandemic. However, this is nothing new since studies over the recent decade have shown this to be the case and have also raised the issue of inadequate staffing. Together, these severely affect the quality of care for older people. The report by The Health and Social Care Inspectorate [31] outlined how the lack of trained RNs and insufficient access to physicians meant that those with little training were left to perform work tasks that they did not have the professional skills to perform, and these staff members often also had poor Swedish language skills. IVO [31] states to be alarming since this greatly jeopardises the safety of older people. In other words, what our study and several other studies on the pandemic have found is that this issue exists regardless of whether there is a pandemic.

In total, 208 CCNs responded to the survey. In Sweden, there are approximately 400 CCNs; as such, the response rate was around 50%. The number of RNs who responded to the survey was 909, and according to the National Board of Health and Welfare, there were 13,983 RNs employed in the care of older people in Sweden in 2019. This means then that a limitation to this study could be the response rate among the RNs, which was approximately 6% and thus very low considering the high number of potential respondents. We did not ask the respondents about the place at which or the municipality in which they worked for reasons of confidentiality which meant that we could not combine and compare the responses of the CCNs and RNs by municipality.

Another limitation is that the survey was not tested among CCNs and RNs and evaluated prior to the data collection. Some of the questions in the survey were questions asked by the Public Health Authority in spring 2020. However, the number of responses to the open questions was high. Of RNs 93% and of CCNs 99% responded to the question about Prerequisites for the prevention of the spread of infection. Of the RNs and CCNs, 92% and 95% respectively responded to the question about Prerequisites for the provision of good medical care and nursing care, which gave more descriptive and substantial data about the situation for the two groups during the pandemic and also confirms the responses to the questions with fixed-response alternatives.

The answers of the CCNs to the open-ended questions were generally more positive in terms of the descriptions they gave of the care that was provided compared with the descriptions provided by the RNs. However, this may reflect the reality they worked in during the pandemic. There was a heavy burden on RNs due to the spread of the virus at RCFs and the fact they worked frontline. The role of the CCN was more administrative for example, they presented guidelines and instructions, and facilitated collaboration between the care organisations in the municipality and the region. The open-ended answers also give an idea of the experiences of CCNs and RNs in the first wave. Another limitation may be that the answers were not in-depth as no interviews were conducted, which can affect results. However, many respondents wrote answers on the open-ended questions that were very long and describing. The analysis of the open-ended questions was done in collaboration with all authors with the first author (AS) taking the lead. The analysis was discussed in the research team until consensus was reached so as to ensure trustworthiness.