Rural Home Care Nursing During COVID-19

Abstract

Background

The SARS-CoV-2 (COVID-19) pandemic continues to be a challenging time for the nursing profession globally. Research indicates that the care of patients with COVID-19 has caused significant psychological stress for nurses. Although much of the world's attention has been on nurses working in emergency departments and intensive care units, the pandemic also posed significant challenges for nurses providing home care services in rural communities.

Purpose

The purpose of this work was to describe the experiences of rural Canadian home care nurses during the early stages of the COVID-19 pandemic.

Methods

The data for this analysis was derived from a study that explored the continuing education needs of rural home care nurses. Since the data collection for the primary objective occurred in the early stages of the COVID-19 pandemic, COVID-19 related themes were created using interpretive description methodology. Snowball and purposive sampling were used to recruit rural home care registered nurses who were employed in the central and southern areas of a western Canadian province.

Results

Six themes were constructed from the data including: Nurses Must Work, Constant State of Flux, Threatened Safety, Loss of Learning Opportunities, Fearing the Unknown, and Hindsight is Easy.

Conclusion

The experiences of rural home care nurses during COVID-19 reflects the chaos, uncertainty, and fear that was felt globally. Based on the findings of this study, recommendations for future pandemic planning are suggested.

Background & purpose

The SARS-CoV-2 (COVID-19) pandemic has been a challenging time for nurses. In most countries, the demands on nursing practice have been unrelenting. Existing research indicates that the COVID-19 pandemic has caused significant psychological stress for nurses (Gillen et al., 2022; Labrecque et al., 2021; Ren et al., 2021; Sultan et al., 2022) including burnout (Sayilan et al., 2020; Sullivan et al., 2021), anxiety (Gao et al., 2020; Garcia-Martin et al., 2020; Kackin et al., 2020; Labrague & de los Santos, 2020; Sadati et al., 2020), exhaustion (Liu et al., 2020; Tan et al., 2020), and depression (Kackin et al., 2020; Tan et al., 2020). The situation was compounded by additional workplace disruptions related to staffing shortages (Sugianto et al., 2022), lack of equipment (Kackin et al., 2020), and lack of personal protective equipment (PPE) (Sadati et al., 2020). Despite these challenges, nurses around the world have not backed down and continue to put their personal safety at risk for their patients (Zipf et al., 2021).

Although much of the focus during the COVID-19 pandemic has been on nurses working in emergency departments and intensive care units, those who work in home care also faced significant COVID-19-related challenges (McEnroe-Petitte, 2021). In client homes, there exists a parallel risk for transmission of infection from the nurse to client (McEnroe-Petitte, 2021; Porzio et al., 2020) and from the client to the nurse. The continued provision of home care services, while keeping both nurses and clients safe, required novel strategies such as telephone triaging (Porzio et al., 2020), telenursing (Kord et al., 2021), and remote virtual care (Kesavadev et al., 2021).

In their day-to-day work, rural home care nurses typically have limited technical and human resources (Canadian Association for Rural and Remote Nursing, 2020), but provide care that requires a broad knowledge base and skillset (Doolan-Noble et al., 2021). Compared to their urban counterparts, rural nurses experience additional stressors including work-related travel (Pavloff et al., 2015), expanded scope of practice (MacLeod et al., 2017), and professional isolation (MacLeod et al., 2021).

In rural communities, nurses must respond to crises despite unique challenges with respect to disaster preparedness and response due to resource limitations, geographic isolation, and lower staffing levels than in urban areas (Brewer et al., 2020). During disasters and other crises, nurses in rural areas are called to assist with disaster management as they are aware of local resources, are relied upon for support, and are seen as experts (Kulig et al., 2017). There is very little published research on the effects of the COVID-19 pandemic on home care nurses. The dearth of COVID-19 related research led one nurse-academic to issue a call on behalf of the International Home Care Nurses Organization for studies to inform home care policies and interventions to ensure quality client outcomes (McEnroe-Petitte, 2021).

The pandemic challenged the delivery of home care. In this study, rural home care nurses reflected on their experiences during the COVID-19 pandemic. The research question for this analysis was: “What were the experiences of rural home care nurses during the COVID-19 pandemic?”

Methods and procedures

The data for this analysis was derived from a study that explored the continuing education needs of rural home care nurses. Since the data collection for the primary objective occurred in the early years of the COVID-19 pandemic, participants were eager to discuss the challenges experienced in provision of home care services to rural residents and COVID-19 specific themes were created. After ethical approval was obtained from a university research ethics board and operational approval from a provincial health authority, snowball and purposive sampling were used to recruit rural home care registered nurses who were employed in the central and southern areas of a western Canadian province, primarily agricultural in nature. For this study, rural was defined as non-urban communities with a population of less than 10,000 people (du Plessis et al., 2001). Participants were also asked to self-declare as currently working in rural home care.

Data were derived from twenty semi-structured telephone interviews conducted from December 2020 to May 2021. Interpretive description methodology guided the inquiry and analyses (Thorne, 2016). Using “retrospective interpretation” (Thorne, 1998, p. 548), themes were constructed from the data that were unrelated to the primary research question.

Findings

Twenty rural home care nurses volunteered to be interviewed for the study. All participants identified as female. Most participants were over 30 years of age, degree-prepared, and were experienced registered nurses (all >6 years of experience, and most had more than six years of experience in rural home care (Table 1). Six themes were constructed from the data including: Nurses Must Work, Constant State of Flux, Threatening Safety, Loss of Learning, Fearing the Unknown, and Hindsight is Easy (see Figure 1).

Table 1.

Demographic characteristics of participants (n = 20).

Category	n (%)
Age
20-29	1 (5)
30–39	9 (45)
40–49	4 (20)
50–59	3 (15)
60+	3 (15)
Highest level of education
Diploma	4 (20)
Post diploma	1 (5)
Degree	15 (75)
Years employed as an RN
0–5	0 (0)
6–10	5 (25)
11–20	7 (35)
21+	8 (40)
Years employed in rural home care
0–5	7 (35)
6–10	2 (10)
11–20	6 (30)
21+	5 (25)

Figure 1.

Rural home care nursing during COVID-19.

Nurses must work

Nursing staffing issues in rural areas are not uncommon. The COVID-19 pandemic exacerbated these staffing concerns. One participant in this study was told by their employer, “Don’t get COVID because we need you to work” (Participant 9). During the COVID-19 pandemic, nurses were often required to ‘cohort’; that is, to limit themselves to one place of employment to decrease the potential for transmission of the virus from one site to another. Thus, if a nurse worked in acute care and long-term care, they were only allowed to work at one site. One participant explained, “there was no casual staff due to COVID because the one [nurse who] worked [casual] with us [in home care], … was working in long term care so she couldn’t come and help us out” (Participant 11).

Other participants were denied days off, including earned vacation because of staffing shortages. When denied her vacation time, Participant 5 stated:

I sent an email back in the capital letters that said: ‘YOU ARE NOT PAYING MY VACATION OUT BECAUSE WE DON’T HAVE STAFF BECAUSE OF COVID. YOU GUYS NEED TO FIGURE SOMETHING DIFFERENT OUT’ because I mean, it's not our fault that we can’t take our vacation, that there's no staff to replace us, right?

Another participant explained, “the workload is so bad, and people's social lives are non-existent, especially if you’re a nurse” (Participant, 17). The COVID-19 pandemic was a difficult time for participants who were unable to work from home and were expected to show up to work. What is more, many participants were denied their earned vacation and did not want to call in sick as there would be no one to replace them.

Constant state of flux

Participants reported that pandemic-related changes happened very frequently and every time they went to work, they had to quickly catch up on all the changes since their last shift. Participant 4 explained, “I don't think there's an easy road map to get educated about stuff that was changing too fast, too often, when they [leaders] didn't know themselves.” Participant 2 shared, “In the beginning, it was just a nightmare.” On needing to adapt to the ever-changing COVID pandemic environment, Participant 17 observed:

This whole journey through the pandemic – things have been in a constant state of flux because we’re adapting and we’re changing what we’re doing, based on the information that's rolling out … it's in real time, right? We’re learning more about the virus and we’re changing what we’re doing and how we’re handling things.

Participant 9 felt that the constant change made life at work feel disorganized, which affected their lives outside of work:

I just feel like it's unorganized, and then it affects your life because when your shifts are changed, or they don’t know when the vaccine's coming. Oh, well you have to work today or we’re switching your shift because nobody's working this day. It's tiring.

There were many changes to nursing practice during the COVID-19 pandemic including worries about personal safety (PPE, COVID-19 testing) and loss of access to learning opportunities. Participant 11 noted that their work was “a whole different ball game because of COVID.”

Threatened safety

During the COVID-19 pandemic, participants’ safety was threatened. There were challenges related to accessing and using PPE and home care nurses’ role in safe COVID-19 testing. PPE-related safety challenges were unique, as Participant 10 revealed, “there wasn’t any home care specific education on PPE donning and doffing.” Participant 4 explained some of the safety challenges that home care nurses faced when donning and doffing PPE:

[In] the hospital, you just do it before you go in the room. But like in a community or in the country you’re pulling up to the farm or whatever, you have to get out of the car, put it [PPE] on, go in and then take it [PPE] off outside in the winter.

Participant 1 had similar experiences, “I have definitely doffed in a rainstorm with my plastic bag sitting open on my driver's seat, with my hand sanitizer on the side of my door. Me and every other home care nurse.” Some participants had never worn gowns and goggles as a rural home care nurse prior to the COVID-19 pandemic. Participant 8 elaborated:

I was really appreciative of that [additional education] because I wasn’t wearing a lot of PPE routinely. Or, if I was, I wasn’t worried for my life if I took it off wrong. That's maybe a bit of an exaggeration, but with COVID when it first started, it's terrifying as a healthcare provider, it's terrifying as a home care nurse because I know my patients need me but that also means that I’m going into their homes. They’re telling us not to see people and that's all I’m doing is seeing people. So, I found that super beneficial, they literally sent out two-minute videos on how to properly don and properly doff your PPE and then it was the kind of thing that once you did it all the time you knew what you were doing. But at the beginning I admittedly did not know. Like the order in which to doff – I didn’t know that I’d just take stuff off and wash your hands in between and try not to touch anything else.

There were also many uncertainties about the availability and utilization of PPE. At the beginning of the pandemic, there was a widespread shortage of PPE for all health personnel, so it was rationed. Participant 7 explained,

… we couldn’t wear it [PPE] unless we knew that they [the client] were positive … I think it's just a stressful time for everyone and if we suspected something, we were only given so much PPE in the day.

In addition to PPE-related safety challenges, participants were also asked to assist with COVID-19 testing when rapid antigen tests became available. The nurses involved in administering tests were emailed instructional information, including a short video, on how to perform a nasopharyngeal swab. Participant 3 was instrumental in setting up the first ‘drive through’ clinic in the province:

I got called in, I think that afternoon at about 3:30 not knowing what I was coming to … There were no supervisors, nothing, and nothing set up. That was kind of a bad situation. So, did it our way – drive through. We set up a drive through … There were no testing centers at the time when this first started.

Participant 19 explained the alarm expressed by some community members when home care nurses from their community were testing for COVID-19, “… nobody wants to come within 20 feet of you – you’re in full hazmat.” Participant 2 shared, “In the beginning, it was terrifying. I’d never done a nasopharyngeal swab before. Not that it was beyond me, but we got a five-minute YouTube video, this is how you do it, go do it, good luck.”

Other participants described how they were on their own to learn how to test for COVID-19. Participant 20 explained, “I don’t know that anybody actually got shown, not that they need to be shown, but we were just directed to do testing for COVID. I just kind of read the policy and then you go do it.” This was echoed by Participant 10: “I said, ‘I haven’t done a nasopharyngeal swab ever’, and then they just gave me a handout and said, ‘here, watch this video’.”

Loss of learning opportunities

During the COVID-19 pandemic, many participants did not have access to opportunities for continuing nursing education and those opportunities that did exist were COVID-19 related. Although some participants in the primary study indicated that newly hired nurses did not always receive orientation to their role, Participant 14 explained that the loss of learning opportunities was exacerbated by the pandemic:

… New hires aren’t getting the footcare course because of COVID, so I’ve had to alter the schedules to make it so that the RNs that do have that training work the wellness clinic and it would have to be an RN that has the footcare course … so it kind of puts a damper on our scheduling.

When discussing the available continuing education, participants replied that everything was related to COVID-19. Participant 15 shared, “It has been so focused on COVID per se, nothing's really been offered in my case manager role. It's just been really focused on vaccines.” Participant 5 started, “because of COVID we haven’t had the opportunity to do that annual education for about two years now … It's mostly COVID these days!” About wanting to learn new things related to client care, Participant 12 observed, “Before COVID, I would say I would have had more questions, now nobody seems to care about anything.”

The opportunities for participants to learn from their educators decreased during the COVID-19 pandemic. As Participant 10 explained:

With COVID, we’re not having regular nursing meetings anymore. So, you want to talk as a group to see how you problem-solve things in other areas, and we’re not even getting that opportunity anymore to have that forum. Usually, I would call my educator and say, ‘hey, I’ve got this new client coming out, I’ve never done this’. Usually, she's so good, she’ll just jump in her car, and she’ll maybe meet me at the client's house the first time and walk me through. This was pre-COVID because now suddenly when COVID hit, then she became the testing site lead, and she was stuck being in that facility all the time. So really in the last 12 months, our education has been really suffering because that educator wasn’t available to even help us out.

Fearing the unknown

Participants reported having significant fear about the COVID-19 pandemic. In the early days, when little was known, they went to work feeling as though they may be putting their lives on the line every day. Participant 4 was “worried for [her] life” if she improperly doffed her PPE. The nurses also talked about their perceptions of the fears their clients were experiencing:

I think, too, for our clients when I think about even simple masking – it scared them, it so scared them. It looked like we were coming in already infected and that's why we were wearing a mask. So, you’d have to explain to them, ‘No we are protecting you because we are out and about around other people so we’re wearing masks to protect you’. (Participant 12)

Participants also spoke of having many questions about the COVID-19 pandemic that were not being answered. Participant 7 said that although she had a lot of questions and wanted to know what was going on with the COVID-19 pandemic, she had to disengage slightly, “I don’t watch the news every day because it's draining. I just can’t, I had to quit.”

Some participants also felt that they were the last to know about COVID-19 updates or new information. Participant 15 talked about the fear nurses felt because of not knowing what was coming next:

I personally felt that nurses were the last to know what was going on, like there was these pandemic meetings the manager would be involved in, and I understand that they’re busy and stuff, but it would be like, we would be the last to know, but yet we’re dealing with the clients. Or we would be told something, and we were just told to do it, but with no explanation and then just thinking about and we’re like, this doesn’t make sense, where is this coming from? It's just, we always felt we were the last to know.

Some participants reported receiving COVID-related information via the news and felt very frustrated by this since they were the ones working on the front lines and required up-to-date information to perform their job safely. Participants would have liked to be informed of policy changes before the general public. There was an overall feeling that communication to front-line nurses during the pandemic was poor. Participant 17 shared:

I feel like it would be thrown on the news before we even knew what was going on and so it was very frustrating to know, I don't know, there's just different rules or different things and we weren't even updated like the public was updated first.

Hindsight is easy

Although the pandemic is ongoing at the time of this writing, participants had some thoughts about post-pandemic planning. All of the participants were surprised by the severity of the COVID-19 pandemic and the impact it had globally. To many participants, the whole pandemic response seemed very reactive because no one was prepared. As Participant 8 shared, “I feel like we were just, like reacting rather than – we weren’t [preventative] in any of this – anything.”

Despite the situation the participants found themselves in, there was some hope expressed for post-pandemic nursing. In terms of continuing education, participants thought the move to online learning was one good thing to come from the pandemic. Participant 10 stated:

I think there are going to be some good things that come out of COVID. I think there already has been, in that just a lot more online access to some of these things [educational opportunities] it really forced people and programs to go virtual, just because that was their only option.

Another participant (Participant 16) reflected how online conferences became more readily available throughout the COVID-19 pandemic. She was hoping that some of the opportunities for virtual learning would continue post-pandemic, as it increased accessibility to events that she would not be able to attend if they were only offered in-person. In-person learning opportunities were often inaccessible because of lack of coverage and the cost of travel to an urban setting.

Looking back, some participants felt that they let their clients down when home care services were suspended during the initial months of the pandemic. Participant 16 shared, “I think initially when we cut services, we kind of closed the door on people and so I think they maybe felt that they [the clients] were a little bit abandoned.” Participant 3 explained:

They [leadership] said they were going to use the priority codes in the pandemic. You’re just given the lingo. But when things were actually shut down in March, and we had to say, ‘yes you get a visit’ or ‘no you don’t get a visit, it was kind of like oh crap. I can’t believe this actually got put into place! I never really paid attention to the pandemic plan because I kind of was living in an oblivion that it was ever going to happen.

Overall, “Could things have been done better? Yeah, I’m sure they could, but hindsight's so much easier than foresight” (Participant 8).

Discussion

The experiences of rural home care nurses during the COVID-19 pandemic were challenging and complex. The findings of this analysis suggest that the pandemic caused significant stress, burnout, frustration, exhaustion, fear, and loss of learning opportunities for rural home care nurses. The themes reflect concerns about the inability to take earned time off and a sense that they had no choice but to work; the rapid pace of change; and, pandemic-related fear and anxiety.

The current findings echo those in a study of Indonesian nurse mangers during the COVID-19 pandemic (Sugianto et al., 2022). The authors reported a reduction in nursing staff and an increase in the number of patients during the pandemic. The nurse managers described feeling exhausted and stated that patient care was not ideal due to lack of staff (Sugianto et al., 2022). This aligns with the present study in which participants also experienced exhaustion and staffing shortages.

The home care nurses’ concerns about PPE are similar to those reported by Sadati et al. (2020) who studied nurses employed at COVID-19 specific hospitals. At the beginning of pandemic there were many unknowns about the SARS-CoV-2 virus that led to uncertainty about PPE. In the Sadati et al. (2020) study, participants were not sure how much (if any) PPE was required when working with patients, who may or may not be infected. The stress related to PPE was also cited by rural home care nurses in the present study who were unsure how to protect themselves in the beginning of the COVID-19 pandemic when PPE was in short supply.

The findings of this analysis also resonate with studies that reported that the pandemic caused significant psychological stress for nurses (Gillen et al., 2022; Ren et al., 2021; Sultan et al., 2022). In their study, Gillen et al. (2022) found that work-related quality of life and wellbeing declined significantly for all health care providers (including nurses) during the pandemic. The same authors also found decreased well-being, increased use of negative coping strategies, and increased burnout amongst health care providers. In the present study, some participants revealed that their quality of life decreased and they had to disengage from the news because it was overwhelming. These rural home care nurses stated they relied on news broadcasts for updates about the pandemic and they felt they should have updates related to COVID-19 before the general public.

This analysis identified several novel contributions to nursing knowledge. First, staffing concerns for rural home care nurses during the COVID-19 pandemic have not been explored in the literature. This is an important area for consideration, as the pandemic exacerbated pre-pandemic staffing shortages and point to a need for studies on safe staffing levels, particularly for rural home care nurses.

Secondly, this analysis highlighted challenges with PPE experienced by rural home care nurses, which are also under-studied. Consideration of PPE is a crucial area for exploration, given the ongoing need for rural home care nurses to have access to and safely use PPE. It is vital that rural home care nurses have access to PPE, so they are prepared for the next pandemic and to provide care to clients isolating at home due to other infectious illnesses.

Thirdly, this analysis revealed the unique stressors that rural home care nurses faced during the COVID-19 pandemic. Based on the findings of this study, it is clear that continuing nursing education was paused during the pandemic. It is important to recognize that nurses required both COVID-19 and non COVID-19 related continuing education, such as orientation and ongoing learning to provide safe, competent clinical care to their patients.

Strengths and limitations

There were several strengths of this study. Using interpretive description, the interviewer/analyst reflected on their role as researcher and, therefore, as an instrument in the study, allowing for transparency in processes and enhancing rigor. Second, the semi-structured interview format enabled participants to share their experiences about the COVID-19 pandemic even though the original research question was not pandemic-related.

A limitation in this study was the potential for researcher confirmation bias as the global pandemic may have led the interviewer and research team to hypothesize that everything related to COVID-19 was going to be a challenge. However, this was minimized by the interviewer and research team challenging their own pre-existing pandemic-related assumptions through personal reflection and seeking optimism throughout the transcripts.

Recommendations for nursing practice

The findings of this study point to a need for a system through which rural home care nurses have access to updates and new information in real time. Prioritizing pandemic-related updates will empower rural home care nurses to make changes to their practice as required. If rural home care clinical nurse educators are re-assigned to other duties during pandemics, policies must be created to ensure that rural home care nurses have access to continuing nursing education supports through other means.

Furthermore, rural home care nurses need access to all types of PPE required for future outbreaks. The lack of PPE and uncertainty about its use at the beginning of the pandemic added to the fear of the virus and how to prevent it. Research suggests that virtually facilitated simulation exercises that supported rural nurses to practice safely donning and doffing PPE during the COVID-19 pandemic are effective (Labrecque et al., 2021).

Pandemic planning must include mental wellness support for nurses. Participants in this study highlighted their feelings of fear and lacking timely information during the COVID-19 pandemic. Rural home care nurses must be provided with support to manage fear and unprecedented events during a range of situations such as infectious disease outbreaks. In a study conducted by Labrecque et al. (2021), online asynchronous Facebook focus groups was found to be an effective strategy for peer support during the COVID-19 pandemic. Nurse peer to peer support has also been identified by Pavloff (2022) as the most frequent way that rural home care nurses support one another in their clinical roles. This may be replicated during pandemics to have an informal mental health support system where nurses with shared experiences can debrief in a safe space.

McEnroe-Petitte (2021) stated that all nurses who work in home care faced COVID-19-related challenges and there is a need for additional research in this area. At present, the literature on the experiences of rural home care nurses during the COVID-19 pandemic is scarce. The present study adds to important information to this knowledge gap and provides new insights into important considerations for rural home care nursing.

Conclusion

The participants in this study shared how the COVID-19 pandemic was fraught with unknowns. Participants felt compelled to work, despite their fear and lack of timely information. The COVID-19 pandemic created rapid, unexpected change for rural home care nurses and exacerbated long-standing staffing issues, lack of access to PPE, and fewer opportunities for continuing nursing education. Understanding the experiences of rural health care nurses during the COVID-19 pandemic provides important insights into gaps that exist for supporting rural home care nurses. The findings provide important considerations for future policy and workplace changes.

Author Biographies

Michelle Pavloff, BSN, RN, MN, PhD, Research Chair, Rural Health, Saskatchewan Polytechnic.

Mary Ellen Labrecque, NP, PhD, Associate Dean Academic and Assistant Professor College of Nursing, University of Saskatchewan.

Jill Bally, BsN, RN, BA(Psych), MN, PhD, Associate Professor College of Nursing, University of Saskatchewan.

Shelley Kirychuk, BScN, MSc, MBA, PhD, Associate Professor Department of Medicine, College of Medicine Canadian Centre for Health and Safety in Agriculture.

Gerri Lasiuk, RPN, RN, PhD, Associate Professor College of Nursing, University of Saskatchewan.