COVID-19-related trauma and the need for organizational healing in a Dutch nursing home

Abstract

The nursing home sector was disproportionally affected by the COVID-19 pandemic and consequently, extreme mitigation strategies were taken in order to halt the spread of the virus. This research scrutinizes the manifestations of organizational trauma and healing amongst nursing home employees during the slow-burning pandemic. We aim to advance the contemporary debate around organizational healing that exclusively investigates fast-burning crises by translating these theories to a slow-burning crisis. Using participatory action research, we conducted two months of visual ethnographic fieldwork in a small-scale nursing home located in Amsterdam, the Netherlands from October to December 2021. Here, we present our findings constituting text and short videos according to the following four themes: (1) Emotional challenges in the workplace; (2) Cultural incompatibility of infection control strategies; (3) Navigating the ethics of decision-making; and (4) Organizational scars and healing perspectives. We propose the new concept of trauma distillation to describe and analyse how simmering organizational wounds are re-opened and purified to trigger a prolonged healing process in the context of slow-burning crises. Ultimately, this may lead to the acknowledgement and acceptance of such organizational wounds as multi-layered and intractable, aiming for a theoretical and empirical understanding of how to heal these. Our use of visual methods offers employees the opportunity to share their stories, make their suffering heard, and may contribute to nursing homes' processes of healing.

1. Introduction

Worldwide, life has been distorted by the outbreak of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) and associated mitigation strategies. Yet, in the nursing home sector, the impact of the COVID-19 pandemic has been particularly damaging (Andrew and McNeil, 2022). Residents of nursing homes are considered amongst those most vulnerable to the virus, because of comorbidities and an often weakened immune system. In the Netherlands, more than half of all COVID-19 related deaths occurred in nursing homes during the first six months of the pandemic (Gilissen et al., 2020). Nursing home employees were amongst those most likely to contract the virus in their work place and now belong to the list of occupations with the highest Long COVID rates in the Netherlands (van Deursen et al., 2022). These high levels of physical vulnerability are compounded by overburdened healthcare systems, disruptive socio-economic impacts, and the devastating impact of social isolation due to visitor bans and distancing measures (Chu et al., 2021; Abbasi, 2020). This meant that, globally, those living and working in the nursing home sector carried a high burden of the pandemic (Giebel et al., 2022; de Vries et al., 2022; Paananen et al., 2021; Wu, 2020).

In February 2022, the Dutch Safety Board published a report that described the country's COVID-19 response strategy, in which they concluded that the nursing home sector suffered a ‘silent disaster’ (Dutch Safety Board, 2022). Especially during the first phase of the pandemic, the Dutch government mainly focused on infection control and limiting the number of COVID-19 patients in intensive care units. Meanwhile, little attention was paid to nursing homes. The government failed to ensure an adequate supply of Personal Protective Equipment (PPE) and diagnostic tests in this sector. This contributed to the high number of deaths among residents and led to many employees falling ill (Dutch Safety Board, 2022). By paying attention to the challenges and failures of the COVID-19 crisis response in nursing homes, the Dutch Safety Board is taking a first step in understanding the pandemic's disastrous effects within this sector. With this paper, we want to shed light on how this silent disaster has unfolded, which scars it has left behind, and what efforts are needed in response.

This ethnographic study examines the varying manifestations of employees' COVID-19-related trauma and associated healing strategies within all organizational levels of a Dutch nursing home. Ethnography allowed for a detailed, all-encompassing description of employees’ experiences with COVID-19. This enhances understanding of how the pandemic has traumatized them and why organizations in this sector can be considered as wounded. COVID-19 is often defined as a collective traumatic event, wherein people experience a genuine fear of injury or death triggering high levels of stress (Stanley et al., 2021; Muldoon, 2020). However, how these traumas enfold is not straightforward, since they may encompass a broad range of experiences. Understanding COVID-19 related trauma is essential in order to comprehend what efforts are needed to heal them. We used the concepts organizational trauma and organizational healing as a lens to further develop this understanding.

Organizational trauma refers to the process in which external factors inflict harm onto organizational members (Mias de Klerk, 2007; Kahn, 2011). This process finds its origin within individual members of the organization, but is then projected onto the organization as a whole (Mias de Klerk, 2007). Specifically when multiple members experience harm from external factors, their collective pain results in the organization itself being considered as wounded (Kahn, 2011). Healing these wounds, then, is what can be called organizational healing: a process in which organizations not only recover from trauma, but strengthen themselves in the process (Powley and Piderit, 2008).

Recovering from organizational trauma is an inherently social process and cannot occur in isolation (Mias de Klerk, 2007; Domínguez-Escrig et al., 2021; Kahn, 2011; Powley, 2009; Powley, 2013). Because organizational members often collectively identify themselves with the organization, many are motivated to play a key role in the recovery process (Powley, 2012). The social process of recovery after trauma manifests in two common practices: empathy and collective story-sharing (Mias de Klerk, 2007; Kahn, 2011; Powley, 2009). Empathy fuels sensitivity among organizational members when responding to others' traumas, which turns them towards rather than away from each other in times of crisis (Kahn, 2011; Powley, 2012). Additionally, empathy strengthens social networks within organizations, therefore strongly influencing the extent to which an organization is able to bounce back from trauma (Powley, 2012). Collective story-sharing allows members to compassionately witness others’ traumas (Powley, 2009). This is because sharing trauma takes the sting out of traumatic experiences and organizational members can find consolation in the thought of not being alone in their suffering (Mias de Klerk, 2007). Both empathy and collective story-sharing are thus key to understanding the degree to which an organization is able to heal. Both these processes are grounded in leadership that allows for collectivity amongst organizational members, making leaders the drivers behind organizational healing processes (Domínguez-Escrig et al., 2021; Kahn, 2011; Powley, 2012). It is therefore crucial to understand the role of leadership in organizational healing.

The main role of leaders is to provide a safe space in which processes of empathy and collective story-sharing amongst organizational members can be facilitated (Mias de Klerk, 2007). In doing so, leaders let go of their formal leadership role and lead out of care and compassion, developing a positive dynamic in which organizational members can connect (Domínguez-Escrig et al., 2021; Powley, 2012). Besides letting go of their formal role, leaders also play a crucial role in removing anxiety around talking about emotions. ‘The leader's role is to legitimize conversations that might be considered culturally illegitimate’ (Kahn, 2011: 81). By taking on this role, leaders also need to participate in the collective efforts to confront trauma, and thereby must deal with their own trauma as much as other organizational members (Mias de Klerk, 2007). An engaged and empathic leader is thus key to facilitating an environment in which formal organizational rules make place for affection with and compassion for others.

Similar to the healing of a physical wound, organizational wounds ‘need to be opened and cleaned before [they] can heal; the unsymbolized needs to be symbolized and experiences need to be brought into awareness, accepted and acknowledged’ (Mias de Klerk, 2007: 38). With our ethnographic approach, which provides insights into the experiences of members of a Dutch nursing home, we aim at contributing to this metaphorically opening and cleaning of the organizational wounds left by the COVID-19 crisis. Currently, organizational healing theories all focus on acute crises with a clear hot phase and aftermath (Powley, 2009, 2012; Powley and Piderit, 2008). Instead we will shift the focus to the slow-burning aspects of the COVID-19 crisis, characterized by a prolonged incubation time, an unclear beginning or end, and rapid escalation towards tipping points (Boin et al., 2020). Our findings do confirm the need for collectivity in responding to traumas and the crucial role of leadership in creating an environment in which these traumas can be freely discussed and healed. However, we show that organizational trauma from slow-burning crises additionally requires other components of healing. Therefore, we propose the new concept of trauma distillation to describe and analyse how simmering organizational wounds are re-opened and purified to trigger a prolonged healing process in the particular context of slow-burning crises. Ultimately, this may lead to the acknowledgement and acceptance of such organizational wounds as multi-layered and intractable, aiming at a theoretical and empirical understanding of how to heal them.

With the use of visual methods, we contribute to this collective process of healing by offering employees the opportunity to share their stories and make their suffering heard. The presentation of text and short videos offers an alternative way of communicating the indeterminacy and complexity of experienced worlds conveying thoughts, sensory responses, and emotions to enhance an empathetic understanding (Macdougall, 2005; Lammer, 2007). This has generated a nuanced, and potentially for some readers an upsetting or triggering, picture of how nursing home staff have physically and emotionally responded to the slow-burning COVID-19 crisis.

2. Methods

From October to December 2021, we conducted two months of ethnographic fieldwork, using participatory action research (PAR), in a small-scale nursing home located in Amsterdam, the Netherlands. Using the dynamic characteristics of PAR, we tailored our research to the specific needs and challenges of the nursing home (Kidd and Kral, 2005). This process of designing the research was a collaborative effort between researchers and respondents, ultimately resulting in the co-creation of the research objective, data collection, and data analysis (Pearce et al., 2020). PAR empowers employees of the nursing home sector to share their concerns (Glasson et al., 2008) about their traumatic experiences during the pandemic.

In collaboration with representatives of the nursing home, we approached fifteen employees for in-depth interviews (1–1.5h), including the nursing home director, team leader, geriatric specialist, medical doctor, client board member, spiritual care taker, communication manager, host, the activities coordinator, receptionists and secretariat members. Additionally, we interviewed four (somatic) residents and their families. During participant observation, we had twenty informal conversations with these same respondents. By then, data saturation was reached. Interviews were semi-structured in order to guide the conversations towards respondents' personal experiences during the pandemic from March 2020–December 2021, as well as their perspectives on the organization's crisis response strategy. Questions covered experiences with the pandemic, feelings of vulnerability, risk perception, and crisis response, e.g. coordination, collaboration, decision-making, communication, and sensemaking of mitigation strategies. Participant observation provided additional insights into the daily experiences of residents and employees within the nursing home and generated rich data about the social and cultural context.

Embedding creative methods into research pathways is key to PAR to generate data and disseminate findings in engaging ways, to create a platform wherein respondents can speak up, and to provide a fertile context for collaborative reflexivity and shared learning (Abbasi, 2020). Through this creative approach, we aim for developing not only valuable scientific knowledge, but also action in practice (Janamian et al., 2016). Together with respondents, we decided to use visual ethnography.

ALC and CJ jointly conducted the ethnographic fieldwork. ALC audio-visual recorded all participant observation and in-depth interviews with a professional HD camcorder on a tripod or handheld. One respondent did not want to be video recorded and was only audio recorded. The unstructured character of data collection allowed for an active role of respondents in guiding the focus of the camera and the content of the visual narrative. In the beginning of participant observation, respondents felt a bit awkward because of the presence of the camera. We minimized reactivity over time by stimulating nursing home employees to continue their work (Brooker, 1993), allowing us to gradually become part of their daily routine. During interviews, the camera played a less central role, because it was placed in a corner on a tripod. After the fieldwork, ALC and CJ did the montage of short videos embedded in this manuscript and shared a draft version with the selection of respondents who appear in the videos for feedback. Currently, we are additionally working on an ethnographic film about COVID-19-related trauma in nursing homes in collaboration with our respondents that is specifically targeted at nursing home employees.

Our visual ethnography approach, which creatively expresses narratives, allowed for a deeper interaction with those putting their trust in researchers to document their stories (Sandercock and Attili, 2010). We used the inherently collaborative and reflexive elements of visual ethnography to engage on a deeper level with our respondents, which facilitated understanding of those perspectives normally omitted from the bigger story (Goopy and Kassan, 2019; Schermbi and Boyle, 2013). The use of images and video additionally evokes empathy and calls for social justice (Degarrod, 2013). Following this line of reasoning, the trauma that we portray in videos becomes an embodied experience for viewers rather than a mere sight. In turn, this may trigger an empathic response and, more importantly, social and collective processes of knowledge creation. Knowledge becomes interactive, emergent, and creative, stimulating new forms of thinking amongst viewers (Degarrod, 2013). Researchers and respondents function as a catalyst in the process of meaning-making, as eventually the meaning of images will always lie in the eyes of the viewer (Pink, 2003). Ultimately, both the collaborative and empathic characteristics of videos (and film in general) give visual ethnography the potential to evoke social change.

We used an inductive approach to analysis. In-depth interviews were transcribed verbatim and screened multiple times by ALC and CJ to identify structures, meaning, and context. Transcripts, fieldnotes, and videos were coded into categories and subcategories using thematic content analysis. This led to the emergence of themes and patterns based on what respondents deemed important to emphasise, avoiding researcher bias. We used Qualitative Data Analysis and Research Software (ATLAS.ti, 9th edition).

Ethical clearance for the study was obtained from the HERoS Ethics Committee and the VU University Ethical Committee (reference number RERC/21-06-1). All respondents were asked for written informed consent before recruitment, interviews, and participant observation. We only approached residents who were generally in good health and able to give consent. We described that the goal of our research was to collect and share the stories of their experience during the pandemic. Furthermore, we explained we wanted to communicate their voices in the writing of academic and non-academic multi-media articles, the making of short videos, and an ethnographic film (in progress). Additionally, respondents signed a consent form discussing the ethical considerations of partaking in a visual ethnographic research. They were informed they would not remain anonymous and they gave permission for presenting the visuals, amongst others, in this multi-media article, the forthcoming ethnographic film, and online.

3. Findings

We arranged our findings according to the following four themes: (1) Emotional challenges in the workplace; (2) Cultural incompatibility of infection control strategies; (3) Navigating the ethics of decision-making; and (4) Organizational scars and healing perspectives. We use the words of our respondents, presented here in both text and short videos, to illustrate our findings and engage readers with the lived experiences of employees in the nursing home sector.

3.1. Emotional challenges in the workplace

The pandemic took a high emotional toll on employees within nursing homes. The director of the nursing home explained how some employees had shared their traumas with her. Noticing how many employees in her nursing home struggled with processing the pandemic, she had strongly suggested trauma as a focus of this research. In her opinion, it was important that these traumas were known throughout the organization, so everyone would be able to act accordingly. Indeed, during our fieldwork employees explained that even though they sporadically talked amongst each other during the first wave of the pandemic, they felt they had not yet looked back upon that period much. Often, our interview was the first time that employees genuinely reflected on the hot phase of the crisis. Realizing the traumatic experiences they had encountered triggered a range of feelings, and some felt so overwhelmed that they started crying.

A nursing home host described how surreal it felt to go to work during a time in which the outside world had fallen silent. While being at work, it was impossible to process the chaos in the nursing home. But she explained that when she came home, the emotions of the day overwhelmed her. She thought about all these residents who tested positive and feared that they would die abruptly, she may never see them again, and would be unable to give them a proper goodbye. A medical doctor explained that there were cases in which a COVID-19 patient seemed fine at the end of her workday but their situation worsened so rapidly during the night, that they were on the verge of death the next morning. She rarely had to deal with such situations before COVID-19. A nurse similarly described the overwhelming emotions employees had to deal with during the pandemic, but additionally emphasized the importance to not show your own stress when interacting with residents in order to not cause them distress. This meant that employees were often left to carry the emotional burden of the pandemic by themselves.

Another emotional burden was a sense of guilt amongst employees, who got ill and were unable to work. The nursing home sector was already short-staffed and this was further amplified by the pandemic. For example, a doctor explained how they decided to cut the regular shift time in half because it was no longer doable to work such long hours due to the heavier workload of caring for COVID-19 patients and the added emotional efforts it required to provide this care. Whereas these challenging working conditions increased feelings of solidarity and teamwork, employees falling ill explained they had the feeling that they abandoned their colleagues. Those employees who had been ill during the first months of the pandemic described an internal struggle between wanting to return to work as soon as possible and being afraid to further spread the virus.

Besides these feelings of guilt, there was also a lot of fear amongst employees. This was especially during the first wave, when so little was known about the virus. For example, there was a lot of discussion around who was going to work in the COVID-19 unit. The fear for the unknown consequences of contracting the virus triggered a lot of tensions. Especially flex-workers, who also worked in other nursing homes, often refused to work within the COVID-19 unit, afraid to contract and spread the virus. This meant that core staff, who felt most responsible for their residents and the team, had to put their feelings of hesitancy aside, and get the work done. Some employees described how they struggled with a fear of death.

Photo 1.

Nursing assistant walking through the corridor.

I thought I might die. Suddenly, I was crying, crying. People would call me, send me messages. It made me feel very vulnerable, because I could feel they were there for me. Suddenly, the tears started. I was like that for two days, I could not stop crying. I never experienced something like that. It was such an intense time. – Nursing assistant

The video related to this quote is here.

The following is the Supplementary data related to this article:

The fear to contract the virus was further amplified with another sense of guilt, because of the possibility to pass the virus on to household members. A few employees even explained they were sleeping on the couch in order to limit the risk of infecting their spouse, or described how family did not allow them to be in the same room. When this, however, would not be enough to prevent spreading the virus and they infected someone, employees explained this was very confronting. A medical doctor described that she infected her husband, who got very ill and had difficulty breathing at night and how that made her feel very guilty.

Besides employees' feelings of fear and guilt, they were also the ones who had to carry the burden in supporting residents through emotional and distressing events during the pandemic. Undoubtedly, the most challenging and emotional measure was the visitors ban, the closing of nursing homes for several weeks. The empty words ‘visitor ban’ meant in real life that loved ones could not be together, sons and daughters were not able to take care of their mother or father, and grandparents could not see their grandchildren. Most heart-breaking were the accounts in which people died alone and family members were unable to say their goodbyes. One host described it as a moment gone, a loose end that can never be tied up. Because of the visitor ban, residents could not be supported by friends or family in these times of loss and fear, consequently leaving employees as the only ones who could guide them through these difficult times. However, most employees were wearing face masks, tried to limit contact, and kept physical distance where possible out of fear for infection. Not being able to console residents because of these rules meant employees often had to see residents suffer from a far.

Photo 2.

Resident of a nursing home.

You could really see residents declining. Sometimes I used to think, two weeks ago you looked a year younger. And now, suddenly, just a certain dullness. It makes you realize how important human contact is. It was very difficult to witness. – Host

The video related to this quote is here.

The following is the Supplementary data related to this article:

Amongst family members, the visitor ban brought up the question of whether the entire closing of nursing homes was a justified measure to combat the spread of the virus. One family member told us how he saw his mother's health deteriorate rapidly during the pandemic. With tears in his eyes, he explained that after the lockdown period, his mother no longer recognized him. Unfortunately, his experience is not an exception. He, but also the daughter of a resident who past away, wondered whether those residents spared of COVID-19 might have died of loneliness in the meantime. Employees were the first point of contact for distressed family members, requiring additional efforts in dealing with their emotional responses. Receptionists had multiple encounters with angry and frustrated family members during the visitor ban. Because of the rapid decline amongst residents, the grief amongst many family members, and inhumane circumstances surrounding deaths, there was a general consensus among employees that, even though it was an understandable decision at the time, the closing of nursing homes should not ever happen again.

3.2. Cultural incompatibility of infection control strategies

Both management and employees explained that the nursing home was ill-prepared for the COVID-19 pandemic. There was barely any protective gear or tests provided by the government, no vaccines developed yet, and very little knowledge of the crisis that was bestowed upon them. This lack of knowledge was particularly evident in the guidelines issued by the National Institute for Public Health and Environment, which were often unclear, ever-changing, and contradictory. The sector was challenged to largely improvise a make-shift crisis response. This crisis response included little of the normal work conditions that included a focus on quality of care and a home-like feeling for their residents. Suddenly, their whole approach had to be replaced by strict infection control strategies.

One of the infection control strategies in the first weeks of the pandemic was the creation of a temporary COVID-19 unit in what previously had served as the nursing homes restaurant. Some employees described this COVID-19 unit as one the most traumatizing experiences of the pandemic. The dehumanizing effect it had on residents was something they found hard to digest, and created feelings of being helpless and unable to resolve the situation. A nurse told us that, in order to protect all other residents, they had no other choice than to isolate residents who tested positive, even if it meant some had to see their fellow residents die in front of their eyes.

Photo 3.

Nursing home manager talking about the COVID-19 unit.

At some point, I sent someone a text. I have it on my phone, shall I read it out? The arranged COVID-19 unit was one big, excuse my language, shit-show. When I had a look on Monday morning, there were dirt and laundry bags all over the floor, screaming residents hanging over their beds, mattresses stacked up against the wall, empty wheelchairs piled up together, curtains held together by clips. I felt like crying. All this, under my supervision. My god. We cannot do this. – Nursing home manager

The video related to this quote is here.

The following is the Supplementary data related to this article:

Because of the harsh conditions within the temporary COVID-19 unit, the nursing home decided to transfer their residents to the larger unit of their sister nursing home. This, however, asked for a large compromise from employees in their standard of good care, as this went against the promise made during admission that residents could stay in the nursing home until their death. One medical doctor explained that it was particularly hard for her to accept that she had to let her residents die in a place where they did not know anyone. This sense of powerlessness characterized the first months of the pandemic for employees.

To successfully implement an infection control strategy, the nursing home received assistance from the Dutch army. The involvement of the army was meant to create order in the chaos caused by the unknown elements of the virus. One nurse explained that, with their expertise in infection control and setting up field hospitals, the army changed the homely atmosphere of the nursing home to a more hospital-like setting. Some employees described difficulty with the army's approach, which often abandoned the elements of good care of a nursing home and did not place the well-being of their residents first. This was hard for employees, because of the close relationships they have with their residents. The uncertainty surrounding the virus, the rapid rise in the number of COVID-19 cases, and the cultural shift in care-giving, amplified a sense of unfamiliarity and alienation amongst many employees. However, notwithstanding the stress caused by the enforced infection control strategies, some employees did mention a sense of comfort due to their belief that the army was capable of controlling the spread of the virus and limiting the number of infections.

3.3. Navigating the ethics of decision-making

Many employees made a comparison with war when describing the circumstances in the nursing home during the first few months of the pandemic. One nursing assistant described that she felt she entered “survival mode” whenever she went to work, actively numbing herself from her emotions in order to deal with the situation at hand. The director of the nursing home described that employees were put in the middle of the horrors of the pandemic, unable to escape because they felt responsible for residents' extensive and ever-continuing need for care, fueling traumatic experiences amongst healthcare workers.

One of the traumatic experiences resulted from nursing homes not being provided with PPE. Because of nation-wide shortages at the start of the pandemic, the government only supplied hospitals with the necessary protective gear. Then, home employees decided to re-use protective gear or work without during the first weeks of the pandemic. One of the medical doctors described that the re-use of face masks resulted in various employees getting sick and having to be admitted to the intensive care unit, with one colleague of hers dying from COVID-19. This left a devastating impact on most employees and the organization.

Photo 4.

Host serving coffee and tea in the nursing home.

One of my employees in charge of the health and safety department, she had to answer hundreds of phone calls from terrified health workers every day. She had to tell those people, because that was the government policy, you have to come to work even when you are coughing. You have to continue working until you have a fever. You cannot get tested, because we do not have enough tests. Stop complaining, keep working. […] I felt very responsible for that policy. It was such a wrong policy. Eventually a health worker also died. […] So, that is my trauma. That I did not say at the time, this is nonsense. We are not following this policy. That I could not protect her from the feeling that the whole department has now; that they had to sentence people to death. Because that is what they did. – Director of the nursing home

The video related to this quote is here.

The following is the Supplementary data related to this article:

The trauma caused by the continuation of work without PPE was amplified by a sense of impending doom. One resident told us that during the lockdown period, when residents were not allowed to leave their room, he realized that many people were dying and tried anticipating the next person who was about to die. In the sister nursing home, half of the residents died during the first wave of the pandemic, leaving employees and residents with images of empty hallways. The manager of the nursing home described this image as one she has not been able to get out of her head, even though more than a year had passed. Employees continued delivering care with the risk of spreading and getting infected with the virus. Nevertheless, they tried as best as they could to continue care and minimize the number of infections. Employees from all organizatinal levels explained that in their eyes they were left no other choice, since they felt responsible for their residents. At the same time, they carried the burden of this – in their words – ‘wrong’ policy.

A sense of responsibility was felt throughout the organization, with the majority of employees blaming themselves for the decisions made. One respondent even described a conversation with another team leader in which they critically reflected on feelings of responsibility and the conflicted decision they had to make to send people to work without protection. They were even wondering whether they would be on the ‘wrong side’ during war, since they had followed top-down orders although they considered the policy inhumane. Strikingly, both employees and management looked at their own roles and responsibilities whilst assessing the crisis response in nursing homes. They did not blame others, such as the government, who strongly recommended these policies in nursing homes. There was such a sense of chaos and inevitable suffering for both residents and employees, that employees felt they were solely responsible for the negative consequences of the infection control strategies.

Photo 5.

Nurse taking care of nursing home resident.

It was difficult. And every new wave it is still difficult. When I look back, I think we did well considering the equipment and knowledge we had. Looking back, I realize how difficult of a situation we were in. I do think we always kept our head in the game. We did the best we could in dire circumstances. Does not make it any easier though. – Medical doctor

The video related to this quote is here.

The following is the Supplementary data related to this article:

3.4. Organizational scars and healing perspectives

The circumstances in nursing homes during the first months of the pandemic were to such an extent traumatizing that employees expressed it was hard to share their experiences with the outside world. They feared that it would be too challenging for an outsider, who did not witness the experience, to fully comprehend what nursing homes went through. It was for these reasons that some employees turned towards each other during this time of crisis. One medical doctor explained that she sometimes sat together with other medical doctors to eat some pizza and ask each other how everyone was doing. She described that in these moments, she felt most seen in her suffering. She also stressed that it was particularly difficult that they were not able to hug each other during these emotional gatherings. She explained that the regular support system amongst many employees was disrupted due to staff shortages, making it even more difficult for employees to find support during hard times. Various employees confirmed that there was no time during work to have an in-depth conversation about each other's feelings and experiences with the pandemic.

The increasing number of cases meant that staff constantly had to provide care where it was needed most, letting go of permanent teams. There were also stories about employees, who got infected with the virus and came back to the nursing home with half their residents who had died and no known colleagues to console them. Whereas death is not something new to employees in the nursing home, during the pandemic, employees' perspectives on death changed, because of the large number of residents that died in such a short time. The disruption of the colleagial support system during times when so many residents were dying further burdened healthcare workers, a trauma they have yet to recover from.

Photo 6.

Communication between nursing home employees.

You just notice people have not fully recovered yet. […] People get angry straight away. Getting defensive more quickly. In general, you are fine, but as soon as there is another COVID-19 outbreak, you start seeing the scars. A resident dies of old age, but all COVID-19 traumas come back for the nurse, who was there. Another person who dies. Yes, it is a nursing home. But that does not take away the pain. – Medical Doctor

The video related to this quote is here.

The following is the Supplementary data related to this article:

Scars were also visible when there were new outbreaks in the nursing home. A pervasive feeling of panic, prevalent during the first wave, was quickly triggered whenever one or more departments had to go back into lockdown. One resident described this panic by giving an account of his morning walk: one of the nurses had anxiously told him that he had to go in quarantine right away, because there was another outbreak. Panicking about getting residents back in their rooms, the nurse had completely forgotten to put on her face mask. The director and manager of the nursing home similarly described how repressed emotions, such as lack of control, feeling unsafe, or anxiety, were fueled by new positive COVID-19 cases. The manager compared it to emotions around the loss of one's parents, feelings that will never fade and instead become experiences you carry with you for the rest of your life.

When asked what could possibly help in treating the scars left by the pandemic, employees expressed that they felt comfort in talking to colleagues. A host described that she felt there had not been a moment to collectively process everyone's traumas and therefore it was hard to find closure. She said that employees know that they can inform management or colleagues about their suffering, but that she herself was not very prone to do so, needing a bit more of a push. She felt it was important to have a more organized aftercare throughout the organization, based on sharing experiences and asking everyone how they are really doing. The spiritual care taker emphasized this need for a processing of collective trauma and explained that confrontations with death often bring up delayed questions that require time, reflection, and conversation to be processed and answered. Whilst the nursing home director explained that they were trying to offer professional help to employees, she also acknowledged people would benefit most from learning about other people's trauma in order to be able to comprehend and process their own experiences. She emphasized the need to pay attention to traumas, especially from the first wave, and explained that she considered this research as a form of recognition that everyone is allowed to have their own traumas.

4. Discussion

Looking at the circumstances in nursing homes during the pandemic, and the consequences it had on employees, one starts to understand why these experiences go beyond personal traumas but rather form a wound on the organization as a whole. Various employees felt left alone in their suffering, being first-hand witnesses to the gruesome effects of the virus and associated mitigation strategies. This was further amplified by a lack of focus on the nursing home sector within the Dutch crisis response. Nursing homes were not prioritized in the early stages of the pandemic, which led to the inadequate supply of PPE, testing equipment, and support for these facilities. A focus on organizational healing may provide a better understanding of how nursing homes can respond to traumas experienced by healthcare workers during the COVID-19 pandemic, and how to move forward. Borrowing from physiological healing processes, organizational healing is best understood by means of a three-step process: inflammation; proliferation; and remodeling (Powley and Piderit, 2008; Powley, 2012). Below, we will explain how these stages of healing illustrate the process of trauma recovery within the nursing home. Moreover, we will further enhance the theory on organization healing by translating it to a slow-burning crisis.

First, in the beginning of the pandemic, the nursing home was in the inflammation stage, which is characterized by the immediate care of those most vulnerable to the inflicted harm, the supply of resources to respond to the initial harm, as well as prepare for the next stages of the healing process (Powley and Piderit, 2008; Powley, 2012). For the nursing home, the focus during this stage was on taking care of residents, but also on incessantly protecting them against the virus, which asked employees to put their own needs aside. Employees had ‘care for the most vulnerable’ at the center of their attention, despite not having the necessary protective gear. Preparing for the next phases of the traumatic event was complicated in the context of this slow-burning crisis, since the crisis continued to exist.

Inherently related to this stage of organizational healing is an organization's capacity to learn. This means to learn from past experiences as well as from external influences, and transfer this knowledge amongst organizational members (Basten and Haamann, 2018). For the nursing home, this meant to embrace the help of the army and learn from their experience with infection control in order to be able to provide this care for residents. The army provided additional resources, but required adapting to a cultural shift in work approach for employees. Employees had to counterintuitively let go of their image of ‘good care’ in order to protect residents from the virus. Employees' struggle with measures, such as the visitor ban, face masks, and distancing, is similarly reported in a UK study about the mental well-being of staff, families, and residents (Giebel et al., 2022) and a Finnish study with a central focus on the perspectives of residents' family members (Paananen et al., 2021). However, our research additionally emphasizes the impact of inhumane care related to improvised, temporary COVID-19 units, the transfers of dying residents, and the prioritization of infection control over residents' well-being. The collaborative efforts of the nursing home's employees to adapt to these changes showed great strength, as organizational learning is particularly challenging in this already overburdened sector due to staff shortages and budget cuts (Lyman et al., 2022). It is in this sense of collectivity that the nursing home took the first steps towards healing its internal wounds, which becomes even more evident in the later stages of the healing process.

Next, in the stage of proliferation, organizational members collectively share the burden of trauma and connect emotionally in order to strengthen internal relationships (Powley and Piderit, 2008; Powley, 2012). Again, in this particular context of a slow-burning crisis, new crisis scenarios and associated traumas arose everyday. Consequently, such an extensive collective effort between organizational members to jointly juggle emotions was hardly possible during the first months of the pandemic, which were characterized by continuous disturbances. This partially resonates with a study in the UK that described how nursing home employees' anxiety about the virus continuously fueled stress and burnout, and mental health issues of staff were considered problematic (Giebel et al., 2022). Whereas Giebel et al. reported guilt amongst residents’ family members about having their relative in a nursing home during COVID-19, one of the important findings of our research highlights the guilt experienced by employees. Feelings of guilt were complex and multi-layered, stemming from a variety of different sources, such as the idea to abandon colleagues when falling ill, spreading the virus to others within and outside the nursing home, following inhumane policies, or providing inhumane care.

The process of sharing pandemic-related hardships and connecting emotionally can be fueled by collective recognition of organizational traumas (Powley, 2012). This starts with raised levels of empathy towards each other and acts of collective story-sharing, turning the focus within the organization towards shared rather than individual trauma processing (Chesak et al., 2020). When talking about the efforts to combat the first wave, employees often referred to team-work and a sense of collectiveness as crucial to their initial pandemic response. This resonates with the idea that in order to sustain engagement in the midst of crisis-related changes, having a common goal and motivation is critical (Lyman et al., 2022). The empathy between employees was for some enhanced through the practice of collective story-sharing. Notably, there was a general consensus that talking to colleagues helped in processing the situation at hand. This need was amplified by the feeling that employees had to hide their own fear in order to not frighten residents, drawing them even more towards colleagues in sharing the burden of their trauma.

However, these acts of empathy and collective story-sharing were not evenly spread throughout the nursing home. We only heard accounts of medical doctors, who were more drawn towards each other for emotional support than towards nursing or hosting staff, which can be explained by their close work relations and the similarity in their experiences during the pandemic. However, in order to initiate the healing process for the organization as a whole, and strengthen the internal social relations, it is necessary to have this compassion for each other's trauma throughout different organizational levels and roles. This is where the crucial role of the leader becomes evident, as it is in their leadership that bridges can be created within the organization and the healing process can be spread across all staff (Brown, 1997).

A leader's role changes in times of trauma, as they are no longer expected to be heroes and provide all the answers, but rather need to show vulnerability and become grounded in the collective processing of grief in the organization (Brown, 1997). In doing so, the leader becomes a servant to the healing process and initiates compassion amongst organizational members (Jit et al., 2017). We recognized this servant and grounded leader in the director of the nursing home. Through her efforts of creating spaces to share trauma and showcasing her own vulnerability, we can see initial success in the proliferation stage of organizational healing, as described above. This suggests that the nursing home is currently transitioning to the last phase of the healing process, remodeling, in which a wounded organization returns to previous functionality but additionally enhances protection for future harm, strengthening the organization as a whole (Powley and Piderit, 2008; Powley, 2012).

This last step in understanding organizational healing finds its roots in the idea of letting go of formal organizational structures when faced with crises. Organizational healing, namely, takes place during a state of liminality, in which organizational order is temporarily disrupted and undone by a crisis (Turner, 1969; Powley, 2009). Liminality then serves in creating a temporal space in which existing structures around social and professional relations shift, and new norms allow organizational members to reorient themselves and emotionally respond to crises (Powley, 2009). This is what allows the nursing home director to act out of compassion rather than adhering to formal rules around her role in the directory. The last remodeling stage is also characterized by a ritualist end to this liminal state and a symbolic departure from this temporal space (Powley and Piderit, 2008; Powley, 2012). However, whereas it is understood that the period of liminality can vary (Powley and Piderit, 2008), the existing theories investigate acute crisis with a clear hot phase and aftermath, whereas with the COVID-19 crisis, we can speak of a slow-burning crisis in which these phases are not set by clear borders (t Hart and Boin, 2001). For the nursing home, it is difficult to organize a ritualist return to a post-pandemic state of being, because a dooming sense that the next wave could be right around the corner lingered for a long time. This raises the question whether a ritualist end to the state of liminality is possible in a slow-burning crisis and if this would be the case, when it should take place. Moreover, the traumas of the nursing home sector need to be shared beyond the nursing home in order to address the role of governing bodies in causing certain traumas, such as the lack of PPE and conflicting guidelines.

In sum, organizational healing is a collective and collaborative process that requires engagement and compassion from all layers within (and outside) the organization. The nursing home shows how efforts of empathy and collective story-sharing allow for the first steps of healing traumas suffered during the pandemic. This is enhanced by the director of the nursing home taking on the role of a servant and grounded leader, who allows for these acts of empathy and collective story-sharing to take place throughout the organization. A focus on organizational healing allows for the processing of the trauma of the pandemic beyond recovery and rather takes into account processes of organizational learning in order to strengthen and prepare for future crises. Moreover, an organizational healing approach may provide the necessary means for the nursing home to comprehend how traumas can be collectively addressed, possibly preventing long term effects.

We tried to grasp how this nursing home is healing from a slow-burning crisis, translating theories of organizational healing in an acute crisis to a slow-burning one. For this, we propose the novel concept trauma distillation to describe and analyse how simmering organizational wounds are reopened and purified requiring a prolonged healing process in the context of a slow-burning crisis. However, future research is needed to assess how large-scale nursing homes, or entirely different organizations, experience organizational healing during a slow-burning crisis.

Our visual ethnographic research will contribute to the sharing of the nursing home sector's trauma distillation and initiating dialogues around how to best prepare for future pandemics. These are crucial efforts for the last stage of organizational healing as they allow the sector to strengthen itself rather than merely return to a pre-pandemic state. Moreover, videos allow for the sharing of the stories of the nursing home sector to the wider public, offering ways of understanding the COVID-19 pandemic through the eyes of the employees of this sector. Using visual methods brings into question what platforms can be provided for nursing home employees and what role their voices could play in future policy making. We additionally call for more research on traumatic experiences of nursing home employees and how these can be used to enhance synergy between the sector, researchers, and policy-makers in order to create healthy work environments.

4.1. Limitations and strengths

Our respondents were recruited within one small-scale nursing home characterized by a warm atmosphere and good relations amongst employees and with management. This may complicate the translation of our research to larger nursing homes. Nevertheless, the accounts of trauma we encountered in this particular setting provided useful insights that will help assessing processes of organizational healing within this sector and that may serve as examples in other settings. This research focused on the somatic department of the nursing home and, consequently, we have not scrutinized the experiences of residents and employees of other departments (for example residents with dementia). The strengths of our ethnographic research encompass a critical assessment of the experiences of the nursing home employees during the COVID-19 pandemic and how this resulted in existing traumas throughout the organization. By engaging on a deeper level with our respondents through participatory action research, we provide insights into their complex experiences of trauma. By showcasing these experiences in short videos, we aim to share the devastating stories of this sector and shed light on their often-unheard suffering.

5. Conclusion

Our visual ethnographic study assessed nursing home employees' experiences of pandemic-related traumas and associated healing processes. We advanced the contemporary debate around organizational healing that exclusively investigate fast-burning crises by translating these theories to a slow-burning crisis. Our most prominent findings included emotional challenges in the workplace, cultural incompatibility of infection control strategies, navigating the ethics of decision-making, and organizational scars and healing perspectives. Our findings may help the methaphorically opening and cleaning of organizational wounds by increasing understanding of how the nursing home sector suffered and is still suffering from the pandemic, and identifying what is needed for their process of recovery. We propose the new concept of trauma distillation to describe and analyse how simmering organizational wounds are re-opened and purified in order to trigger a prolonged healing process in the context of slow-burning crises. Our use of visual methods offers employees the opportunity to share their stories, make their suffering heard, and contribute to nursing homes' processes of healing.

Credit author statement

Anne Lia Cremers: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing. Cato Janssen: Data curation; Formal analysis; Investigation; Software; Validation; Visualization; Writing – original draft; Writing – review & editing.

Funding

This work is part of the HERoS project, which is financed by the European Union's Horizon 2020 Research and Innovation Programme (grant agreement No. 101003606). ALC and CJ received grants for the BASICS for resilience project from the Dutch Research Council (NWO) for the Dutch National Research Agenda (NWA) routes 21/22 (NWA.1418.22.024) and the Amsterdam Public Health Valorization and Impact projects (2022106).

Declaration of competing interest

We declare no competing interests.

Data availability

Data will be made available on request.