Caregivers' job stress related to oral health care of the elderly in long-term care facilities during a prolonged COVID-19 pandemic

doi:10.21203/rs.3.rs-3346109/v1

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Research Article

Caregivers' job stress related to oral health care of the elderly in long-term care facilities during a prolonged COVID-19 pandemic

https://doi.org/10.21203/rs.3.rs-3346109/v1

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Background

The COVID-19 pandemic has been a great ordeal for elderly individuals and their caregivers. Oral health care for the elderly during the pandemic would be burdensome for those in long-term care facilities. Therefore, we confirmed caregivers’ behavioral practices and stress related to oral health care and infection control for the elderly in long-term care facilities after the COVID-19 outbreak, their relationship with job evaluations, and changes according to the prolonged pandemic.

Methods

Two surveys were administered to 215 and 201 caregivers working in long-term care facilities in 2020 and 2022, respectively, during the COVID-19 pandemic. The surveys assessed caregivers’ sociodemographic characteristics and job status, infection control behaviors, psychological stress in providing oral health care to the elderly during the COVID-19 pandemic, overall job stress and job satisfaction in elderly care, and turnover intentions. We analyzed the pattern in each year, the changing trend from 2020 to 2022, and the correlations among them for the behavioral and psychological impact on caregivers by the COVID-19 outbreak using an online surveying system.

Results

After the COVID-19 outbreak, infection control behaviors (personal protection and cross-infection prevention measures) in providing oral health care to the elderly increased rapidly. The most significant stressor for caregivers in this work was the limitation of their daily lives, followed by the challenge of managing the oral health problems of elderly individuals. A low practice rate of infection control behaviors and high levels of stress related to oral health care and elderly care jobs were correlated with low job satisfaction levels and high turnover intention. As the pandemic extended over three years from 2020 to 2022, infection control behavior practice further improved, and all stressors (e.g., fear, burden, and difficulty) in oral health care for the elderly declined. Although overall job stress in older people’s healthcare was similar, job satisfaction decreased, and serious concerns about job turnover increased significantly.

Conclusions

We identified behavioral and psychological stress and changes in the oral health care of caregivers for older people during the COVID-19 pandemic. Based on these results, we should have a system to support caregivers who care for the elderly to maintain their oral health and quality of life in response to future public health crises.

COVID-19

caregiver

elderly

oral health care

job stress

long-term care facility

The elderly in long-term care facilities often have difficulty leading independent daily lives due to serious illnesses and limited physical and mental activity. The same is true for oral health care, and it has been found that about 70–90% of elderly people in the facilities need help from people around them for daily oral health care, such as brushing their teeth or cleaning dentures [1]. However, caregivers, who are mainly responsible for the oral health care of elderly residents, are unable to provide sufficient the care due to lack of systematic oral health care education and practical experience, other high-priority tasks, and financial reasons [2, 3].

After the coronavirus disease 2019 (COVID-19) outbreak, access to care facilities was almost closed, and the dependence of elderly residents on caregivers increased, which would have significantly added to the overall workload of caregivers [4, 5]. In particular, in terms of oral health care, it was very difficult for elderly residents to go out for dental treatment, and the time caregivers could devote to oral health care would be further limited due to heavy workloads. In addition, oral hygiene care for the elderly was a burdensome task for caregivers due to the nature of dental care, which generates droplets, and the fact that the elderly must take off their masks when receiving oral hygiene care. Thus, the COVID-19 situation would not only have increased the restriction of oral health care work for the elderly, but also deepened the occupational stress of caregivers. Job stress is a factor that hinders organizational performance by decreasing job satisfaction and organizational commitment and increasing turnover rates [6, 7]. Similarly, the job stress experienced by caregivers in the facilities may be a factor that hinders the proper performance of caregiving tasks.

Therefore, we believed that the COVID-19 situation would have brought about direct and indirect changes in caregivers’ behavioral and psychological factors related to oral health care jobs for the elderly, and we conducted a qualitative study targeting caregivers in long-term care facilities. After the COVID-19 outbreak, we confirmed behavioral practices and levels of stress related to oral health care and infection control for the elderly among caregivers in the facilities. We analyzed its relationship with job stress, job satisfaction, and turnover intentions. In addition, we also analyzed trends in behavioral and psychological changes in caregivers due to the prolonged COVID-19 pandemic from 2020 to 2022.

Study participants and data collection

A qualitative study was conducted with two surveys during the COVID-19 pandemic, targeting caregivers responsible for oral health care of the elderly working in long-term care facilities such as residential or daycare facilities in Korea. In this study, caregivers were defined as all care workforces who provide support to older people in care facilities, including care workers (licensed caregivers), social workers, nurses, or nursing assistants, etc. Given the severity of the COVID-19 situation, online surveys were conducted using a commercial search engine (Naver®; Naver, Seong-nam, Korea). This study was approved by the institutional review board of Seoul National University School of Dentistry (S-D20200035, S-D20210012), and an informed consent was obtained from all participants.

The first survey was carried out in October 2020. 224 people responded to the 2020 survey, and the responses of 215 people (91.0%) were finally analyzed after excluding duplicate respondents. The second survey was conducted two years later, from November to December 2022, by revising and supplementing the first questionnaire items. Two hundred six people responded to the 2022 survey, and the responses of 201 people (97.6%) were used as valid responses (see Table 1).

Table 1

The progress of surveys on caregivers working long-term care facilities
Round	Preliminary*	1st survey	2nd survey
Period	Early Oct 2020 (3 days)	Mid Oct 2020 (20 days)	Nov-Dec 2022 (35 days)
Participants	Responders: 20	Responders: 224 Valid responders: 215	Responders: 206 Valid responders: 201

Questionnaire structure

Both surveys consisted of questions to assess the status of caregivers’ jobs related to overall care work and oral health care of the elderly, as well as the behavioral and psychological impact of the COVID-19 crisis on them. The survey was self-administrated. In the preliminary survey, open-ended opinions about the COVID-19 situation of caregivers were collected. The final structured questionnaire was reorganized into multiple-choice questions, short-answer questions, and items to evaluate psychological factors using a Likert scale (out of 5 points) and a visual analog scale (out of 10 points) (see Table 2).

Sociodemographic characteristics and job status of caregivers

The surveys collected sociodemographic characteristics such as gender, age, and education level, and occupational information such as qualifications (certificates) and work experience. The burden of overall nursing care and oral health care duties for the elderly was also assessed, including questions about the caring time per person, the number of elderly responsible for nursing and oral health care, and the level of difficulty of oral health care for the elderly that they perceived. These variables represented the overall job status of the caregivers.

COVID-19 and infection control behaviors

We evaluated the behavioral impacts of the COVID-19 crisis on caregivers. First, as a behavioral factor, we confirmed changes in infection control behaviors during oral health care for the elderly due to the COVID-19 outbreak. We examined whether the caregivers practiced personal protective measures such as hand hygiene, wearing gloves, masks, and face shields, and disinfecting facilities, as well as measures to prevent cross-infection between caregivers and care recipients, such as changing personal protective equipment and staggering time.

COVID-19 and psychological impacts

Psychological impacts by COVID-19 spread were assessed as the stress during oral health care and overall job evaluation. After the COVID-19 outbreak, the stress suffered by caregivers when caring for the oral hygiene of the elderly was measured in three aspects (6 items), including fear (of infection), burden (in infection control), and difficulty (in solving problems). Meanwhile, the job burden felt by caregivers during the COVID-19 situation was evaluated, including overall job stress in elderly care, job satisfaction, and serious concerns about changing jobs due to the COVID-19 crisis.

Table 2

Composition of questionnaire: on caregiver’s job burden for oral health care for the elderly and behavioral and psychological factors related to COVID-19
Categories		The contents of questionnaire
Sociodemographic characteristics		Gender, age, educational background
Occupation information		Qualifications (certificates) and work experience
Job burden (workload)	Overall nursing care	Working hours in facilities, number of older people in charge
Job burden (workload)	Oral health care	The caring time per person, number of older people in charge, and the difficulty level of oral health care for the elderly
Impacts of COVID-19	Behavioral factors	Infection control practices in oral health care for the elderly before and after COVID-19: personal protection (hand hygiene, wearing of gloves, masks or goggles/face shields), prevention of cross-infection when caring for multiple elders (facility disinfection, changing personal protective equipment, distancing or staggering time)
	Psychological factors	Three aspects (6 items) of stresses in providing oral health care to the elderly: fear (of infection), burden (of infection control), and difficulty (in solving oral health problems)
	Psychological factors	Job evaluation: overall job stress in elderly care, job satisfaction, and serious concerns about changing jobs under the COVID-19 pandemic

Statistical analysis

The pattern of sociodemographic characteristics, job information in each year, and differences between 2020 and 2022 were confirmed by cross-analysis or t-test. The implementation rate of infection control behaviors before and after COVID-19 was calculated, and the differences in the current practice rate between 2020 and 2022 were compared by cross-analysis. The psychological variables expressed in VAS scores, such as difficulty of oral health care for the elderly (out of 10), stress during oral health care and nursing care for the elderly (out of 10), and job satisfaction (out of 5), were calculated as the mean score and the differences between two years were compared by t-test. The relationship among infection control behaviors, oral health care stress, overall nursing care stress, job satisfaction, and turnover intention in each year was assessed by Spearman correlation analysis. Statistical analyses were performed using SPSS 25.0 (IBM Co., Armonk, NY, USA) and GraphPad Prism version 5.01 software (GraphPad Software Inc., GraphPad San Diego, CA, USA, RRID: SCR_002798)).

1. Caregivers’ sociodemographic characteristics and job status

The 2020 and 2022 surveys showed that nearly 90% of the caregivers were women, and the average age was 53, with those in their 50s being the most active. About 58% of the caregivers had an associate's degree or higher.

The primary providers of oral health care for the elderly were care workers, followed by social workers, nursing assistants, and nurses. On average, respondents held 1.4 qualifications, with some holding up to 4. The trends in respondent data for 2020 and 2022 showed similarity. Respondents had an average of 5.2 years (2020) and 6.9 years (2022) of working experience as caregivers, with the majority having 4–6 years of experience. On average, they cared for approximately 15 elderly individuals daily and worked for about 8 hours. In 2022, the average work burden of the respondents was slightly higher. Oral health care was provided for an average of 9.1 (2020) and 7.1 (2022) people, with around 5.1 minutes (2020) and 4.3 minutes (2022) devoted to it. In 2022, the time spent on oral health care was slightly more (see Table 3).

Table 3

Socio-demographic characteristics and job status of caregivers: in 2020 and 2022
Categories / Survey year		2020 (n = 215)		2022 (n = 201)		p-value
Variables		N	%	N	%	p-value
Socio-demographic status
Gender	Men	20	9.3	23	11.4	0.521
Gender	Women	195	90.7	178	88.6	0.521
Age (year-old)*		51.6 ± 10.9 (23–90)		53.2 ± 9.5 (26–67)		0.122
Education level	≤ middle school	9	4.2	8	4.0	0.991
	High school	82	38.1	76	37.8
	≥ associate degree	124	57.7	117	58.2
Job information
Qualification (certificate)	Care worker	165	76.7	167	83.1	0.114
	Social worker	94	43.7	68	33.8	0.044
	Nurse assistant	26	12.1	24	11.9	1.000
	Nurse	9	4.2	11	5.5	0.648
	Dental hygienist	1	0.5	0	0.0	1.000
	Other	17	7.9	12	6.0	0.450
	Number of qualifications*	1.45 ± 0.65 (1–4,1)		1.40 ± 0.63 (1–4,1)		0.443
Work experience (years)*		5.20 ± 4.27 (0–19,4)		6.89 ± 4.37 (1–26,6)		< 0.001
Job burden (workload)
General nursing care	Working time (hours)*	7.79 ± 1.69 (1–14,8)		8.24 ± 1.01 (3–14,8)		0.001
General nursing care	Number of elderly people in charge*	14.29 ± 16.74 (1–93,8)		15.69 ± 18.70 (1-122,8)		0.419
Oral health care	Caring time (minutes/person)*	9.14 ± 9.46 (0–64,6)		7.09 ± 6.15 (0–41,5)		0.009
	Number of elderly people in charge*	5.47 ± 6.02 (0–30,3)		4.29 ± 2.68 (0–15,3)		0.011
	The difficulty level oral health care⒂†	6.33 ± 2.30		5.33 ± 2.21		0.005

* Mean ± standard deviation (minimum – maximum, median).

† A score is out of 10, and mean ± standard deviation.

2. Infection control behaviors of caregivers during oral health care for the elderly: before and after the COVID-19 outbreak

We assessed caregivers' modifications to infection control behaviors during oral hygiene care for the elderly before and after the COVID-19 pandemic. We asked whether they implemented personal protective measures for COVID-19 infection control, and actions to inhibit cross-infection between caregivers and care recipients during oral care procedures (see Table 4). According to the 2020 survey, caregivers performing elderly oral health care routinely practiced hand washing/hygiene (80.5%) and wearing personal protective equipment such as gloves (71.5%). These behaviors increased significantly to 98.1% and 92.1%, after the COVID-19 outbreak. After the pandemic, the usage of masks increased rapidly from 28.4–99.1%, while the practice of wearing goggles/face shield also increased to 27.4% from its previous rare usage. The trend observed in 2022 echoed that of 2020, with higher rates of adoption for hand hygiene, glove wearing, mask use, and face shields usage (see Table 4, Fig. 1).

Because caregivers manage multiple elderly individuals, cross-infection is a concerning risk for both care recipients and caregivers. To prevent cross-infection, preventive measures such as hand hygiene and glove changes were already widely practiced prior to the COVID-19 outbreak. However, after the outbreak, the percentage significantly increased to 93.0%, with almost all individuals also disinfecting their facilities (99.5%). Changing masks, cleaning face protectors, and maintaining distance or staggered times between elderly care recipients were not common practices before the COVID-19 pandemic. However, the adoption of these practices increased rapidly to 62.3% and 91.2% after the pandemic. The results for 2022 were similar to those of 2020, with higher practice rates in 2022, except for distancing (see Table 4, Fig. 1).

Table 4. Caregivers’ infection control behaviors during the oral health care for the elderly: before and after COVID-19 outbreak

Survey year	2020 (n=215)							2022 (n=201)
Start time to take an action	Before outbreak	After outbreak		Action*		No action		Before outbreak	After outbreak	Action*	No action	p-value
Personal protection for infection control among caregivers (n (%))
Hand washing/ hand hygiene	173 (80.5)	38 (17.7)		211 (98.1)		4 (1.9)		174 (86.6)	26 (12.9)	200 (99.5)	1 (0.5)	0.373
Wearing gloves	153 (71.2)	45 (20.9)		197 (92.1)		17 (7.9)		162 (80.6)	33 (16.4)	195 (97.0)	6 (3.0)	0.032
Wearing masks	61 (28.4)	152 (70.7)		213 (99.1)		2 (0.9)		69 (34.3)	131 (65.2)	200 (99.5)	1 (0.5)	0.999
Wearing goggles /face shields	3 (1.4)	56 (26.0)		58 (27.1)		156 (72.6)		15 (7.5)	50 (24.9)	65 (32.3)	136 (67.7)	0.282
Control for prevention of cross-infection during caring for multiple elderly people (n (%))
Hand hygiene or change gloves every time	129 (60.0)	71 (33.0)		197 (92.9)		15 (7.0)		163 (81.1)	35 (17.4)	198 (98.5)	3 (1.5)	0.007
Change of masks, wipe of goggles/ face shields	24 (11.2)	110 (51.2)		132 (62.0)		81 (37.7)		54 (26.9)	84 (41.8)	138 (68.7)	63 (31.4)	0.180
Facility disinfection	122 (56.7)		92 (42.8)		214 (99.4)		1 (0.5)	189 (94.0)	10 (5.0)	199 (99.0)	2 (1.0)	0.612
Time lagging or distancing during oral health care	37 (17.2)	159 (74.0)		196 (91.2)		19 (8.8)		59 (29.4)	113 (56.2)	172 (85.6)	29 (14.4)	0.091

* Action refers to the cumulative behaviors implemented before and after the COVID-19 pandemic.

3. Caregivers’ stress during oral health care for the elderly: impact of prolonged COVID-19

After the COVID-19 pandemic, the psychological stress experienced by caregivers providing oral health care for the elderly was measured in three aspects and six specific items: fear (of infection, of getting infected), and burden (careful infection control, restrictions on daily life), and difficulty (problem-solving, receiving expert assistance) (see Table 5).

In the 2020 and 2022 surveys, caregivers indicated that their concern about transmitting the virus to elderly patients (rated 4.48 and 3.85 out of 10, respectively) was higher than their concern about contracting the virus from the elderly (rated 4.38 and 3.64). Additionally, they significantly emphasized infection control measures during oral healthcare (rated 4.91 in 2020 and 4.27 in 2022). However, the most significant stressor for caregivers in 2020 was the restriction of their daily lives (6.93), including a lack of mobility between family members and limited opportunities for social interaction and leisure activities. Because their occupations involve caring for vulnerable individuals at risk of infection, this continued to be the biggest burden (5.97) in 2022. The next most substantial stressor was the challenge of addressing oral health problems. After the COVID-19 pandemic, it proved challenging for individuals to determine the optimal approach to oral health issues (5.90, 5.07) and receive the professional help or advice (5.56, 4.91) (see Table 5, Fig. 2).

As the COVID-19 pandemic continued for almost three years, there was a significant decrease in stress levels for oral health care (difference between scores on 6 specific items in 2020 and 2022, p-value < 0.05). In 2020 responses, the average stress level for oral health care (5.36) was significantly higher than that for overall nursing care work for the elderly (5.08). However, in 2022, the stress for each element decreased significantly (average of 4.61), and it was lower than the overall stress (5.02). However, the stressors were still greater regarding restrictions on daily life and difficulties in solving oral health issues (see Table 5, Fig. 2).

4. Overall job stress, job satisfaction, and turnover intention of caregivers: impact of prolonged COVID-19

We examined the association between caregivers' job stress and job satisfaction regarding elderly care work, their concerns about changing employment in response to the COVID-19 pandemic, and how these factors have changed in the past two years (see Table 5).

In 2020 (n = 215), the average job satisfaction for overall care work was 3.62 out of 5, with 58.1% of respondents reporting ‘high’ or ‘very high’ satisfaction levels. The average overall job stress was 5.08 on a scale of 10, with 28.4% reporting high stress (7–9), 43.3% reporting medium stress (4–6), and 43.3% reporting low stress (1–3). However, in 2022, during the extended COVID-19 pandemic, job satisfaction markedly decreased to a score of 3.39 out of 5 compared to the previous year (p-value 0.001). Furthermore, only 40.3% of caregivers reported feeling ‘high’ or ‘very high’ satisfaction. In addition, the percentage of participants who reported considering a job change due to the impact of COVID-19 rose from 16.3% in 2020 to 26.9% in 2022 (p-value 0.012), negatively correlating with job satisfaction (p-value < 0.001, not shown in Table). Ironically, the average level of total job-related stress in 2022 was 5.02, which was not significantly different from two years earlier (see Table 5, Fig. 2).

Table 5

Caregivers’ psychological stress on oral health care for the elderly and job evaluation in overall elderly care under the prolonged COVID-19 pandemic: in 2020 and 2022
Psychological stress and job evaluation			Score*
Categories		The contents of detailed question	2020 (n = 215)	2022 (n = 201)	p-value
Stress during oral health care for the elderly related to COVID-19 pandemic (out of 10)	Fear	I am concerned about the risk of acquiring an infection while providing oral health care to elderly patients.	4.38 ± 2.48	3.64 ± 2.34	0.002
	Fear	I am concerned about potentially infecting the elderly during oral health care.	4.48 ± 2.64	3.85 ± 2.56	0.013
	Burden	I am concerned about the need for increased attention to infection control during oral health care.	4.91 ± 2.60	4.27 ± 2.45	0.010
	Burden	To prevent infection among the elderly, I have had to significantly restrict my daily activities	6.93 ± 2.87	5.97 ± 3.01	0.001
	Difficulty	It is difficult to determine how to solve oral health problems in the elderly.	5.90 ± 2.52	5.07 ± 2.56	0.001
	Difficulty	It is difficult to obtain expert help or guidance regarding proper oral health care.	5.56 ± 2.50	4.91 ± 2.50	0.009
	Total	The average of six types of stresses	5.36 ± 1.88	4.61 ± 1.80	< 0.001
Job evaluation	Stress	Overall job stress in elderly care work (out of 10)	5.08 ± 2.05	5.02 ± 1.98	0.784
	Satisfaction	Overall job satisfaction in elderly care work (out of 5)	3.62 ± 0.75	3.39 ± 0.71	0.001
	Job change	Serious concerns about job change due to the COVID-19 situation (“yes” or “no”)	35 (16.3%)	54 (26.9%)	0.012

* Score presented the degree of stress as out of 10 and mean ± standard deviation.

5. The impact of behavioral and psychological stresses during oral health care for the elderly under the COVID-19 pandemic on overall job stress, job satisfaction, and turnover intention of caregivers

The study analyzed the correlation among caregiver implantation of infection control behavior (as measured by the number of practiced behaviors out of 8), stress levels during oral health care, and difficulty of providing such care to elderly patients, with overall job evaluation, including job stress, job satisfaction, and turnover intentions. The results of the 2020 survey showed that the lower the practice of infection control behavior, the higher the stress related to oral health care, the greater the difficulty perceived in oral health care, the higher the overall stress related to elderly care, lower job satisfaction, and increased intention to change jobs (see Table 6, Fig. 3).

Table 6. The correlation matrix between behavioral and psychological stresses during oral health care for the elderly and overall job evaluation during the COVID-19 pandemic

Variables	Infection control behavior	Difficulty level of oral care	Averaged stress during oral health care	Overall job stress for the elderly care	Overall job satisfaction	Serious concerns for job change
Infection control behavior	1.000
Difficulty level of oral care	-.224^**	1.000
Averaged stress during oral health care	-.085	.446^**	1.000
Overall job stress for the elderly care	-.097	.443^**	.393^**	1.000
Overall job satisfaction	.055	-.085	-.104^**	-.235^**	1.000
Serious concerns for job change	-.047	.158^**	.163^**	.136^**	-.192^*	1.000

* p-value < 0.01, ** p-value < 0.001.

As society shifts toward a super-aged population, the COVID-19 pandemic has presented significant challenges for older people and their caregivers. The pandemic has threatened the daily lives and healthcare of older people residing in long-term care facilities and has impacted the care workforce [4, 5, 8–11].

Traditionally, caregivers tending to the elderly considered oral healthcare a lower priority and often lacked sufficient training [3]. Moreover, as COVID-19 is a respiratory infectious disease, providing oral health care for the elderly during the pandemic would be perceived as burdensome or unpleasant for caregivers. Therefore, this study aims to observe the infection control behaviors of caregivers, their psychological responses, and its changes in oral health care for the elderly residing in facilities, who are particularly vulnerable to infection during the COVID-19 pandemic.

The survey results revealed that the majority of respondents were middle-aged female caregivers. They provided oral hygiene care, such as tooth brushing or denture cleaning, for approximately 4–5 minutes per person and around ten older people daily. It was not long to care for older people in institutional settings with limited activities and low compliance.

Although the time required for oral hygiene is short, caregivers are taking precautions against COVID-19 to protect the elderly and themselves. According to the COVID-19 infection control guidelines [12, 13], caregivers washed their hands or used disinfectant to sanitize their hands, wore gloves and masks, and used goggles or face shields when providing oral hygiene care to the elderly. There was a noticeable increase in efforts to prevent cross-infection, such as disinfecting facilities, maintaining distancing, consistently following hand hygiene protocols, and changing protective equipment. These practices experienced a further surge in 2022 compared to 2020. However, in 2022, three-quarters of individuals were still not wearing face protectors.

As the COVID-19 pandemic significantly impacts on behavior, it has also caused considerable psychological stress on caregivers. Caregivers have experienced fear of infection, the burden of infection control, and difficulties in problem-solving. As healthcare providers responsible for the elderly, the fear of infection risk was relatively higher for the elderly than for themselves like another study [4]. Amid the COVID-19 pandemic, solving oral health concerns for the elderly was challenging due to limited dental clinic access [14]. Difficulties in solving oral health problems in the elderly were more stressful to them than fear. However, their greatest stress source was the limitation on their daily lives resulting from working in an infection-prone environment. These concerns persisted for over three years. Similarly, in another study, care staff complained that they were suffering from significant isolation while working in nursing homes during the pandemic [15]. It is a fact that the public also considers restrictions on social and leisure activities to be the most stressful factor during the extended COVID-19 pandemic [16]. However, the average stress levels experienced during oral health care were not significantly different from those during overall health care tasks for older people. Therefore, it can be assumed that COVID-19 is not an insurmountable barrier to providing oral health care for the elderly.

Interestingly, over three years, we observed a significant decrease in all six types of stress caregivers experienced during oral health care for the elderly. Even though, after the COVID-19 outbreak, workload increased due to the necessity of wearing personal protective equipment and maintaining strict infection prevention protocols. It is assumed that individuals have adapted to the pandemic and experienced decreased stress during oral health care by following these necessary measures to prevent infection.

To better comprehend the significance of these survey findings, it is necessary to consider the COVID-19 situation and policy actions in Korea at the time of the survey. The first survey was conducted in the fall of 2020, at the beginning of the COVID-19 pandemic, when the incidence rate in Korea was low at a few thousand per month. Nevertheless, social distancing measures and limitations on daily life were stringent [17, 18]. The following survey was conducted in the fall and winter of 2022 when the peak of the COVID-19 pandemic in Korea had passed. At this time, the incidence of COVID-19 exceeded 1 million cases per month, which was significantly higher compared to 2020. However, as mandatory social distancing measures were lifted, and daily life started to recover gradually [17, 18]. For the nursing facilities in Korea, strict social distancing measures have been in place from the onset of the pandemic through October 2022. Afterward, residents were permitted to leave, visitors were allowed access, and close contact meetings were allowed [17, 18]. The changes in caregivers’ stress levels and job evaluations explained below are linked to these situations.

As the pandemic lasted from 2020 to 2022, there was a notable improvement in infection control practices, leading to a decrease in all stressors, such as fear, burden, and oral health care difficulties for the elderly. However, job evaluation showed a different result. Overall elderly care job stress remained unchanged, while job satisfaction decreased from 3.62 to 3.39. Furthermore, there was a notable rise in significant concerns about job changes from 16.3–26.9%. Looking at the progress of COVID-19 in Korea and the policy response during the COVID-19 pandemic, this irony may be the result of adapting to the situation by establishing a crisis response system over the past three years. At the beginning of the COVID-19 outbreak, caregivers did not know how to cope. However, with the establishment of guidelines [12, 13] and increased mastery and practice of protective measures, the vague fear and stress they felt while providing oral health care to elderly individuals may have diminished. However, the restrictive life as a worker in an infection-prone facility is prolonged too long, which makes the caregivers feel psychologically exhausted and unsatisfied. This result corresponds the study reporting that care staff under stressful circumstances during the pandemic had been overburdened often, which caused increased burnout, job change, and workforce shortages in the long-term [15].

Meanwhile, increased psychological fatigue may cause caregivers to give up or become distracted. A study in Korea in 2022 reported that as the COVID-19 pandemic continued for 2–3 years, the public also experienced an increase in information fatigue regarding COVID-19 information and behavioral fatigue, which is a decrease in motivation to participate in health behaviors (89.1%) [16]. Similarly, psychologically exhausted caregivers became less worried and less interested in COVID-19 control when providing oral health care to the elderly. In summary, the behavioral practice increased, and the stress of each sector decreased through establishing a response system and behavioral adaptation. However, psychological exhaustion is believed to decrease job satisfaction and increase turnover intention.

Even if caregivers appear to have adapted psychologically and behaviorally to the pandemic, the fact that job satisfaction is decreasing and concerns about changing jobs are increasing is worrisome. This is because negative perception of the job suggests caregivers’ burnout [15], and can also negatively affect the health and well-being of the older people they care for. A research has shown that the stress of nurses working in intensive care units during the pandemic was high, and their resilience was low; it was important to manage nurses' stress to maintain patient safety and quality of care [19]. Similarly, the oral health and quality of life of the elderly in the facilities depend on the emotional control and well-being of the workers who care for them. Several studies also said that caregivers’ mental health was vulnerable due to COVID-19, so must be managed and supported [4, 5, 10, 11, 20]. The longer a crisis lasts, the less rewarding they find their work and the greater their desire to leave, making it difficult to provide stable nursing care to the elderly [15]. Therefore, help is needed to reduce their workload. Especially considering the possibility of various public health crises and the COVID-19 pandemic, caregiver support systems are essential for the general and oral health of the elderly.

Realistically, how can dental professionals help manage the stress of caregivers in the crisis? In particular, the stress caused by difficulties in resolving oral health problems is an area that desperately needs professional attention. In both the 2020 and 2022 surveys, many people reported that it was still difficult to find solutions or get expert help when dental problems arose in the elderly, meaning that there was no support system for them in the dental field. Therefore, it will be important to build an infrastructure so caregivers can easily communicate with experts to get help and oral health-related information. For this, we have been developing a digital platform that can improve caregivers' access to oral health care information and communication with experts [21]. In addition, in the correlation analysis, the higher the stress and difficulties in oral health care that caregivers felt, the lower the job satisfaction and the higher the intention to change jobs. Thus, the system involved in oral health professionals could help improve job satisfaction and organizational commitment of care workforce in care facilities.

Although the COVID-19 endemic was declared, based on this experience, the dental community as well as public health authorities must prepare for public health crises that may occur in the future. As onsidering the results of this study, oral health officials need to establish a response manual or system that provides collaboration with dental professionals and help to caregivers to continue oral health care for the elderly in the face of possible infectious disease spread.

The limitation of this study

As a qualitative study in the form of a survey, this study has the limitation of relying on the participants’ subjective responses. Because the survey was conducted almost 1 to 3 years after the first COVID-19, memories of practice in pre- and post-COVID-19 may be somewhat inaccurate. Especially in 2022, memories will be vague due to the prolongation of the pandemic. In the 2022 survey, the overall rate of practicing infection control behaviors before COVID-19 was high, possibly related to respondents' memory bias. In addition, the psychological stress score has a fixed range, but because each respondent has different subjective standards, the same score does not indicate the same stress level. Moreover, several factors, such as fear, burden, and difficulties, were evaluated as psychological stress. However, more diverse stress factors affect oral health care for the elderly in the actual field. Also, we did not use formal mental health index or scales [20]. Because of this aspect, it was somewhat difficult to make an absolute comparison with the results of other studies.

The strength of this study

However, this study is the first to evaluate the extent to which COVID-19 acts as a behavioral and psychological burden on caregivers in the provision of oral health care for the elderly in the facilities and what the long-term effects are. Several studies have evaluated the difficulties and systemic problems of oral health care for the elderly in the facilities [2, 3]. However, it is rare to evaluate the impact of the COVID-19 pandemic on these issues.

More than three years have passed since the COVID-19 outbreak began, and most countries have declared the COVID-19 endemic with the WHO's official declaration, returning daily life. Although the spread of COVID-19 is unusual, these public health crises can be repeated and result in restrictions on daily life and health care services including oral health care. Therefore, awareness and preparation on them are necessary in terms of public oral health. Therefore, we have focused on the elderly in care facilities and their caregivers as vulnerable people to the pandemic, analyzed its impact on them, related to oral health care.

Consent to participate

Written consent was obtained from all participants with ethical approval by the institutional review board of Seoul National University School of Dentistry (S-D20200035, S-D20210012)

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors have no competing interests to declare.

Funding

This work was supported by National Research Foundation of Korea (NRF) grant funded by the Ministry of Science and ICT (NRF-2021R1A2C2012515) and National Health Promotion Fund by Ministry of Health and Welfare of Korea (11-1352000-002977-01).

Authors' contributions

Conceptualization & design of the study: JAP, BHJ; questionnaire generation: JAP, HRP, JYL, BHJ; panel recruitment: JYL, SH; data collection and cleaning: JAP, SH; data analysis and interpretation: JAP, HRP; drafting the main manuscript & making tables and figures: JAP; revising of the manuscript: JAP, HRP, BHJ

Han DH, Kim NH, Ko SM, Kwak JM, So JS, Lee SK, et al. Oral health status of institutionalized elderly in Korea. J Korean Dent Assoc. 2015;53(10):688-95.
Gopalakrishnan A, Kahu E, Jones L, Brunton P. Access and barriers to oral health care for dependent elderly people living in rest homes. Gerodontology. 2019;36(2):149-55.
Tsukada S, Ito K, Stegaroiu R, Shibata S, Ohuchi A. An oral health and function screening tool for nursing personnel of long-term care facilities to identify the need for dentist referral without preliminary training. Gerodontology. 2017;34(2):232-9.
Araya AX, Palacios J, Oyanedel F, Iriarte E. Providing Care During the COVID-19 Pandemic: The Experience of Formal Caregivers in Long-Term Care Facilities in Chile. J Gerontol Nurs. 2023;49(5):39-44.
Blanco-Donoso LM, Moreno-Jiménez J, Amutio A, Gallego-Alberto L, Moreno-Jiménez B, Garrosa E. Stressors, Job Resources, Fear of Contagion, and Secondary Traumatic Stress Among Nursing Home Workers in Face of the COVID-19: The Case of Spain. J Appl Gerontol. 2021;40(3):244-56.
CH Cho, MS Kim. An Effect of Nurses` Job Stress on Job Burnout and Job Effectiveness; Focusing on Large-sized Hospital in Daegu,Gyeongbuk Area. Health Service Management Review 2011;5(1):1-13.
McCleese CS, Eby LT, Scharlau EA, Hoffman BH. Hierarchical, job content, and double plateaus: A mixed-method study of stress, depression and coping responses. J Vocat Behav. 2007;71(2):282-99.
Dziedzic B, Idzik A, Kobos E, Sienkiewicz Z, Kryczka T, Fidecki W, et al. Loneliness and mental health among the elderly in Poland during the COVID-19 pandemic. BMC Public Health. 2021;21(1):1976.
De Kock JH, Latham HA, Leslie SJ, Grindle M, Munoz SA, Ellis L, et al. A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being. BMC Public Health. 2021;21(1):104.
Messina A, Lattanzi M, Albanese E, Fiordelli M. Caregivers of people with dementia and mental health during COVID-19: findings from a cross-sectional study. BMC Geriatr. 2022;22(1):56.
Hoedl M, Thonhofer N, Schoberer D. COVID-19 pandemic: Burdens on and consequences for nursing home staff. J Adv Nurs. 2022;78(8):2495-506.
Coronavirus disease 2019 guideline for health care workers. Korea Disease Control and Prevention Agency, Cheongju-si. https://ncv.kdca.go.kr/hcp/. Accessed 10 Sep 2023.
Coronavirus disease 2019 guideline for general public. Korea Disease Control and Prevention Agency, Cheongju. https://ncv.kdca.go.kr/ncov/. Accessed 10 Sep 2023.
Morita I, Sakuma S, Kondo K. Impact of the Coronavirus Disease 2019 Pandemic on Dental Visits in Japan. Oral Health Prev Dent. 2023;21(1):179-84.
White EM, Wetle TF, Reddy A, Baier RR. Front-line Nursing Home Staff Experiences During the COVID-19 Pandemic [published correction appears in J Am Med Dir Assoc. 2021 May;22(5):1123]. J Am Med Dir Assoc. 2021;22(1):199-203.
Summary of the survey on changes in perception of Gyeonggi-do residents for COVID-19. Gyeonggi-do News Portal. Gyeonggi Provincial Office, Suwon. https://gnews.gg.go.kr/. Accessed 20 Jul 2023.
Occurrence trends of Coronavirus disease 2019. Korea Disease Control and Prevention Agency, Cheongju. https://ncov.kdca.go.kr/. Accessed 31 Aug 2023.
Health Insurance Review and Assessment Service. COVID-19, recording history and asking about the future. Health Insurance Review and Assessment Service: Wonju; 2023.
Aqtam I, Ayed A, Toqan D, Salameh B, Abd Elhay ES, Zaben K et al. The Relationship Between Stress and Resilience of Nurses in Intensive Care Units During the COVID-19 Pandemic. Inquiry. 2023;60:469580231179876.
Chen H, Cao Y, Lu Y, Zheng X, Kong B, Dong H, et al. Factors associated with mental health outcomes among caregivers of older adults in long-term care facilities during COVID-19 post-epidemic era in Shandong, China. Front Psychiatry. 2022;13:1011775.
Park J, Han S, Jin B. A suggestion of the new oral health care system for the caregivers at the long-term care facilities. J Korean Acad Oral Health 2022;46:252-9.

No competing interests reported.

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Caregivers' job stress related to oral health care of the elderly in long-term care facilities during a prolonged COVID-19 pandemic

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Material and method

Sociodemographic characteristics and job status of caregivers

COVID-19 and infection control behaviors

COVID-19 and psychological impacts

Statistical analysis

Results

Discussion

The limitation of this study

The strength of this study

Conclusion

Declarations

References

Additional Declarations

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