Home care nurses' and managers’ work environment during the Covid-19 pandemic: Increased workload, competing demands, and unsustainable trade-offs

Little research exists on how home care nursing personnel have experienced the Covid-19 pandemic. This qualitative study explores the work environment related challenges nurses and managers in home care faced during the pandemic. We discuss these challenges in relation to the Demand-Control-Support Model and reflect on how the organizational dynamics associated with them can be understood using the competing pressures model. During the pandemic, home care nurses and managers experienced both an increased workload and psychosocial strain. For managers, the increased complexity of work was a major problem. We identify three key takeaways related to sustainable crisis management: 1) to support managers’ ability to provide social support to their personnel, 2) to increase crisis communication preparedness, and 3) to apply a holistic perspective on protective gear use. We also conclude that the competing pressures model is useful when exploring the dynamics of the work environment in complex organizational contexts.


Introduction
The Covid-19 pandemic has put a heavy toll on healthcare and care personnel. Not only has the workload increased, the pandemic has also been associated with higher levels of psychiatric symptoms such as anxiety, depression and stress (Ardebili et al., 2021;Braquehais et al., 2020;Lamb et al., 2021;Marvaldi et al., 2021;Pappa et al., 2020). Many of the deaths associated with Covid-19 have involved elderly people either living in nursing care homes or receivers of home care (Glynn et al., 2020;Ioannidis et al., 2021). In Sweden, for example, 66% of the deaths related to Covid have involved this group (Socialstyrelsen, 2022). In Sweden, this type of care is provided by nurses, nurse aides and home care aides working for the municipalities. Broadly the term home care refers to any care or service provided in the patients' home that enables the patient to continue to live at home (Genet et al., 2012). Home care nursing on the other hand refer to "treatment and care taking place in the patient's home that is predominately performed by registered nurses" (Larsson et al., 2022, p. 1).
Currently, little research exists on how the personnel working in home care nursing have experienced the pandemic and the challenges they have faced. Given the sheer size of the home care sector and the number of Covid related deaths among the home care patients, this is surprising (Rydenfält et al., 2020;Socialstyrelsen, 2022). In contrast, much focus has been put on the hospitals and the personnel caring for Covid-19 patients there, one example being intensive care units (Caillet et al., 2020;Fernández-Castillo et al., 2021;Greenberg et al., 2021;Heesakkers et al., 2021;Sama et al., 2021). There is no doubt that working at hospitals during Covid-19 has been challenging, and is important to study. However, it is also of great importance to gain knowledge about how other parts of the healthcare system, such as home care, have coped during Covid-19. Among the existing studies, Sterling et al. (2020) investigate the experience of caring for patients during the pandemic among home healthcare workers; Bandini et al. (2021) explore challenges that home care aides met during the Covid-19 pandemic. From a survey addressed to home health and home care managers, Sama et al. (2021) conclude that the managers met substantial challenges related to the handling of the Covid-19 pandemic and that home health and home care needs to be given more attention in pandemic crisis planning. However, few studies consider the experiences of registered nurses working in home care and the situation for home care managers. No studies that we know of have actually investigated how the pandemic has affected the organizational dynamics of home care and how that, in turn, has affected the work environment. Since home care nursing is a mobile endeavor, that often is conducted with little access to support from other professions such as physicians, it is likely that the challenges home care nurses and managers faced during the pandemic differs somewhat compared to hospital-based care.
In this qualitative study we explore the work environment related challenges that home care nurses and home care managers have faced during the Covid-19 pandemic. We also discuss how these challenges affected the psychosocial work environment in terms of the Demand-Control-Support Model and reflect on how the organizational dynamics associated with them can be illustrated using the competing pressures model (Johnson and Hall, 1988;Karasek, 1979;Karasek and Theorell, 1990;Sanford et al., 2022). Finally, we identify three key takeaways important in order to achieve a sustainable work environment during crisis.

Theoretical framework
In the following two sections we first briefly describe the widely applied Demand-Control-Support Model (Johnson and Hall, 1988;Karasek, 1979;Karasek and Theorell, 1990) used to discuss how the pandemic affected the psychosocial work environment. Then we introduce the competing pressures model and the pressures diagram proposed by Sanford et al. (2022). The competing pressures model is used to investigate the relation between the dynamics of the work situation and potential effects on the work environment, and to deduce needs related to the work environment during crises. The two models complement each another since the Demand-Control-Support model is concerned with job strain on the individual level and the competing pressures model with the relation between trade-offs made by individuals and the system or organizational level.

The Demand-Control-Support Model
The model was originally conceptualized as the Demand-Control Model for Job Strain. The model predicts that high levels of work demands combined with low levels of control or decision latitude, result in high levels of job strain, and thus is undesirable (Karasek, 1979). However, an equally important aspect of the model is that low levels of demands per se do not create a good working environment. The desired state, rather, is one with both high demands and high levels of control or decision latitude. Here, decision latitude can be understood as authority or influence over one's work situation (Karasek et al., 1998). Later, a third dimension, social support, was added to the model making it the Demand-Control-Support Model (Johnson and Hall, 1988;Karasek and Theorell, 1990). When it was low, the social support dimension heightened the job strain even further. Here, social support can be described as socio-emotional as well as task related, instrumental support from supervisors and co-workers (Karasek et al., 1998).

The competing pressures model
In a recent study of risk trade-offs in healthcare, Sanford et al. (2022) propose an extension to Rasmussen's (1997) dynamic safety model. Sanford et al. (2022) conceptualize the competing needs that healthcare personnel have to simultaneously adhere to as pressures that have to be balanced. Pressure at work is defined as: "… any aspect of the internal or external organizational context that creates emotional stress, increases the tempo of work, or increases the difficulty of work thus requiring more mental or physical effort" (Sanford et al., 2022, p. 1). They propose five different pressures: efficiency, quality and safety, workload, personal (breaks and other personal needs), and organizational (resources) (see Fig. 1). As in Rasmussen's (1997) original model, these pressures exist around an operating point. The dynamic safety model consists of three boundaries: boundary of functionally acceptable performance, boundary of economic failure, and boundary of unacceptable workload. These boundaries (or pressures) create an envelope in which the system can function successfully. However, the boundaries are associated with needs that when addressed, can push the operating point towards the other boundaries. For example, an accident may occur if economic needs  Sanford et al. (2022). The operating point is in the middle, thus all pressures are adhered to. push the operating point too far towards the functionally acceptable performance boundary and crosses it (Cook and Rasmussen, 2005;Rasmussen, 1997).
Instead of an envelope with three boundaries, Sanford et al. (2022) propose that different pressures can be illustrated by a Venn diagram of overlapping circles that symbolize pressures (see Fig. 1). When all needs associated with each pressure is met, the operating point is placed in the middle of the diagram. In Rasmussen's dynamic safety model, this corresponds to when the system is operating within its boundaries. However, when one pressure is traded off, that is, not prioritized, the operating point falls outside that circle. For instance, if the workers trade off their own workload and thus take on a workload that is unacceptable, the operating point would fall outside of the workload pressure circle. The focus on risk trade-offs is not new. Reader et al. (2018) studied risk trade-offs in relation to patient care, and Hollnagel (2004Hollnagel ( , 2009) has suggested the efficiency-thoroughness trade-off principle to explain trade-offs between production and thoroughness concerns. The benefit of the competing pressures model is that it offers a way to explain more complex relations between different trade-offs (Sanford et al., 2022).

Design
The research design in this explorative study was qualitative. It focuses on the participants' own experiences of working during the Covid-19 pandemic. Data consisted of semi-structured interviews with home care nurses and managers employed in four different Swedish municipalities (Kvale and Brinkmann, 2009). Two of the municipalities could be considered small towns with less than 20,000 inhabitants, and two as towns with between 30,000 and 50,000 inhabitants.

Participants
In total 26 participants were interviewed: 14 registered nurses working as home care nurses, and 12 participants in management positions (home care nurse managers, combined home care nurse and home care managers, home care managers, and a manager for a dedicated Covid-19 group).

Data collection
The interviews were conducted between May and June 2021. Although the Covid-19 pandemic was still ongoing at the time, most of the home care staff and most of the patients had the opportunity to be vaccinated against Covid-19. The first three authors conducted the interviews. The interviews ranged from 33 min to 1 h and 7 min, with a mean length of 47 min. Interview topics included: mobility at work, interprofessional teamwork, work environment related challenges associated with Covid-19, crisis management, and learnings from the pandemic. All interviews were audio recorded and transcribed.

Analysis
The data were analyzed thematically inspired by Clarke's (2006, 2019) reflexive process. First, the data were read by the first author who coded the entire data set from the bottom up in an explorative open fashion. From this initial coding, preliminary themes that covered the entire data set was suggested and discussed in the research group. From these themes, the following overarching theme was selected for further investigation: to work in municipal healthcare and care during . It was concerned with the personnel's experiences of working during Covid-19. Then the data set was coded again, exclusively focused on collating the data related to the overarching theme. The themes and sub-teams related to the overarching theme were generated and discussed until the authors reached agreement.

Ethics
Before the data collection began, the participants received information about the study, that participation was voluntary, and that they could withdraw from the study at any time with no questions asked. They also signed an informed consent form. The study was assessed by the Swedish National Ethical Review Board (DNR: 2021-00703), which decided that the research did not require ethical approval according to Swedish law.

Results
Three main themes were identified related to the overarching theme, to work in municipal healthcare and care during Covid-19: 1) increased workload, 2) psychosocial strain, and 3) changes in practice to decrease transmission.

Increased workload
Both home care nurses and managers experienced an increased workload due to the pandemic. It was the most apparent consequence of the pandemic for the participants in several ways. For example, when asked what implications the pandemic had for one's work, one nurse stated:

It has meant extra work. -Nurse
A manager in another municipality expressed it like this:

Everyone says it. It has been the most intensive year that I have ever experienced, actually. -Manager
We elaborate on the increased workload for nurses and managers, respectively, in the following two sections.

Nurses' increased workload
The main contributor to the increased workload for home care nurses consisted of the effects Covid − 19 had on their patient work. The examples they gave ranged from the testing of patients, to covering for sick or quarantined colleagues, to the use of protective gear. One nurse described the increased workload like this: The home care managers responsible for the home care aides verified the dependence the aides had on the nurses for communicating the information.

Managers' increased workload
Compared to the nurses, the increased workload for managers can be attributed to many more sources. For nurses, the main obstacle was more work, for managers it was more work combined with an increased complexity of their work. Managers became involved in many more tasks related to Covid-19. In several cases, these were tasks of which they had little experience. As a consequence, it became hard to keep up with ordinary management work such as job performance appraisals and being available to provide staff support. As one manager expressed it: Just carrying out salary discussions and job performance appraisals during a pandemic has been terribly difficult. -Manager New tasks or tasks that required more effort included: protective gear purchase, Covid-19 response coordination meetings, emergency call duty, safety routine follow-ups, interpretation of safety routines, contact tracking, care prioritization, ensuring that the personnel were informed about Covid-19 routines, and ensuring that the unit had adequate staffing to meet their basic obligations even when large portions of the regular staff were quarantined or sick.
One manager expressed the general increase in workload and work complexity like this: In addition, the home care managers reported that it was hard to ensure that the staff complied with the prescribed Covid-19 routines. Hence, it also took a lot of effort to communicate routines: It came as a surprise to many of the home care aides, or some of them, because at that time they didn't know about these routines that we had pestered them about for six months. -Manager

Psychosocial strain
A heavy workload was an important contributor to psychosocial strain, but there were also other contributing factors. Fear and anxiety related to Covid-19 was an issue, more so for home care aides than for home care nurses. Nevertheless it was something that worried managers: There are some who are very worried and who have been worried, because they have severely ill relatives at home and are afraid of infecting them ] … …So I actually think that the heaviest factor has probably been the staff's anxiety. -Manager Some home care nurses expressed anxiety about Covid-19, but there were several who stated that they were not that worried about catching Covid-19, rather that they (much like the home care managers) had to help the home care aides mitigate their fear and anxiety. In contrast to the aides, nurses have more education and training in infection control. Thus for them, it was described as "Just pure routine".
Although the nurses did not express so many issues related to fear of catching Covid, managers expressed worry and feelings about not being able to provide enough support to the nurses: It has been stressful and pressing. And then it can be difficult to capture how nurses feel mentally, because you do not have time to focus on it, instead it is something that comes up afterwards. … Crisis managementif you think about all the patients who have died and suchthat hasn't existed. -Manager As stated above, managers also had difficulties finding time for annual job performance appraisals. This picture is mirrored by nurses who stated that there was a lack of management support because the managers were overloaded with work. There were also reports of burnout among other nurses from the participants. Together, this indicates the need for more social support from management, the provision of which was difficult during the pandemic.

Changes in practice to decrease transmission
Changes intended to decrease the transmission of Covid-19 had several effects on the work environment. Although intended to be protective measures, these changes had both positive and negative effects. Still, the participants' faith in the protective measures was high. When asked, most stated that they felt safe and many believed that it was more likely to be infected outside of work than at work.
The participants reported two types of changes intended to protect against Covid-19 transmission outlined in the next two sections: 1) changes intended to facilitate social distancing, and 2) changes that involved protective gear.

Social distancing
Two types of measures intended to increase social distancing were used.
The first included organizational measures that physically restricted the risk for exposure to Covid-19. A common measure was to spread out the personnel. This was achieved, for example, by moving home care groups out to facilities that separated them to decrease the number of people working in the same place.

Our home care group moved out from the location where all the other home care groups and nurses sit. So we have been quite isolated. … We haven't had much spread of the infection among the staff, nor among the patients … -Nurse
Other examples were restrictions in how many people were allowed in common areas like kitchens and dining rooms, and that personnel sometimes went directly from home to the patients instead of going via the office facilities. The participating organizations also introduced restrictions on substitutes, restricting them to a smaller group of patients. They were, for example, only allowed to cover for regular staff in one area at a time. In Sweden, eldercare is to a large degree dependent on substitutes (Strandell, 2020;Winblad et al., 2017). Thus, this had a large impact on work and added additional staffing challenges.

Yes, and it's even happened that we've had to divide the substitutes, so that they don't go into all the areas. So we have assigned them to each unit. So we have had to hire more substitutes to manage it. -Manager
In addition, unnecessary patient visits were avoided. As one nurse explained:

You don't just go on a home visit because you feel you haven't talked to or met this patient for a long time. … You only go out if you really need to, in order to avoid contact. -Nurse
Another example of an organizational measure was to let the exposed personnel who had been the first to discover that a patient had Covid-19 continue to work with infected patients.
The second type of measure intended to increase social distancing was the use of technical measures to constrain the physical interaction. The most basic such change was to replace physical meetings with phone calls: There are more phone conversations. There are not so many physical meetings. -Nurse Other technical measures involved the use of digital technology, and was thus dependent on the digital infrastructure. Starting the workday at home or at a patient's home was utilized to thin out the staff in the office. Some administrative staff also worked remotely. For nurses and staff with administrative tasks, though, this resulted in new demands related to digital mobility. The organizations had to purchase new computers and software in order to enable more staff to work at home.
We have purchased more laptops to equip planners and administrators so they could work from home if they had symptoms, so as not to be so vulnerable. -Nurse Many meetings were cancelled to increase social distancing, especially in the beginning. Personnel education efforts and meetings were moved online to replace physical meetings. One result of these types of initiatives was that the organizations gained new capabilities in digital and mobile ways of working. The ability to have some meetings and educational efforts online was considered positive and something that several participants wanted to continue after the pandemic.

Protective gear
Protective gear measures to decrease transmission of Covid-19 varied during the pandemic. In the beginning (i.e., spring 2020), less protective gear was prescribed in Sweden and there was also a market shortage. While the participants at large stated that they managed to scramble protective gear to meet the requirements, the requirements increased as the pandemic progressed. When the interviews were conducted, the mandate was to use a face mask at all patient visits and when working close to colleagues. When visiting someone with a suspected or confirmed Covid-19 infection, the protective gear also included a visor, apron and gloves, in addition to the face mask. Sometimes, the face mask was replaced by a respiratory protection mask.
In addition to that protective gear use implied an increased workload, the participants expressed two types of work environment issues related to the use of protective gear: ergonomic problems and logistic challenges.
Ergonomic problems were related to heat, skin (including rashes and chafing) and airways. These were sometimes mistaken for Covid-19 symptoms and thus led to employee quarantine. There were also problems with condensation on glasses and visors. One nurse described the ergonomic problems regarding the use of face masks like this: We have to place compresses behind our ears to avoid pain there. And at the time, I had quite a lot of sick days for a while; lots of tests because I often had a sore throat. But I realized after a while that it was connected to the mask. -Nurse A nurse described the ergonomic issues related to protective gear like this:

So the visors worked well … If you also have glasses … and when you also have a mask, it fogs up again, not to mention now in the summer, or yes, it really makes no difference if it is summer, or whatever it is. But when you put on an apron, it's just like you stop breathing. You end up being drenched in sweat. It's not very comfortable, I must say. Then you notice
… the use of masks. There are many whose throats and noses have been affected, and some have rashes that have broken out on their cheeks and such. -Nurse While the personnel generally had faith in that the protective measures would protect them, it is clear that there also was sacrifice and hardship involved on behalf of the personnel.
Regarding logistics, the extensive protective gear use during the pandemic meant that the personnel had to bring much more protective gear with them than previously. Since home care aides and nurses in the participating organizations often moved about using a bike or by foot, they had limited capacity to carry disposable gear with them. For that reason, unused disposable gear commonly was stored in the patients' homes. Another aspect was that used protective gear was not supposed to be left in the patients' home at all. However, in practice it often was impossible to bring it back. A nurse described it like this: Yes, so practical. Of course, there will be huge rubbish heaps for the patients, but for us … yes, you're supposed to bring it with you. You're supposed to bring it with you on the bike. -Nurse Other participants stated that there were complaints from the patients' landlords about the amount of trash that was generated.

Discussion
While getting less attention during the Covid-19 pandemic compared to other parts of the healthcare system, the pandemic has resulted in significant work environment related challenges for home care nurses and home care managers. In this study we explored the overarching theme to work in municipal healthcare and care during Covid-19, with the three sub-themes; 1) increased workload, 2) psychosocial strain, and 3) changes in practice in order to decrease transmission. The increased workload and psychosocial strain sub-themes could be considered to be about things that have become worse. The changes in practice in order to decrease transmission sub-theme is also concerned with changes that do not pose challenges per se, but rather illustrate how the ways of working have been transformed by the encounter with the pandemic.
In the next three sections we first discuss the results from the perspective of the Demand-Control-Support Model (Johnson and Hall, 1988;Karasek and Theorell, 1990). We go on to discuss work environment related trade-offs made by the personnel in terms of competing pressures (Sanford et al., 2022). Lastly, we present a number of key takeaways important in creating a sustainable work environment.

Effects on the work environment of increased demands and decreased control and support
While both the home care nurses and the managers experienced an increased workload, i.e. increased demands, which could lead to increased job strain (Karasek, 1979), the managers' work situation also became more complex. Nurses expressed a desire for more support from their managers. The managers, though, felt that they were unable to provide such support. This is unfortunate as viewed through the lens of the demand-control-support model (Johnson and Hall, 1988;Karasek and Theorell, 1990). Ideally, increased demands could, in part, have been mitigated by increased control and support. However, for the managers, there was a decrease in control because their work had become more complex. Thus, in terms of the demands-control-support model, the managers' situation could be described as strained. Their workload and lack of control also inhibited them from providing more support to the nurses. The managers felt that in order to have time to manage tasks related to Covid-19, they had to relinquish many of the tasks they carried out to promote the wellbeing of their personnel. As the nurses desired more managerial support, possibly due to the increased demands that they experienced, this appeared to be a real problem that could negatively affect the nurses' psychosocial work environment. This is in line with previous research suggesting that insufficient organizational support is associated with higher pandemic-related stress and anxiety levels among staff (Lethin et al., 2021). It is also in line with the Demand-Control-Support model that postulates that increased demands needs to be matched by increased control and support (Karasek and Theorell, 1990).

The work environment and trade-offs between competing pressures
The results of Sanford et al. (2022) indicate that in order to respond to other pressures, it often is personal needs and an acceptable workload that are traded-off. In other words, there is a tendency to sacrifice oneself first. We see that both the home care nurses and managers took on an unsustainably high workload in order to adhere to other pressures.
For the nurses who worked with protective gear, it was clear that personal needs were traded-off. This is illustrated by the personnel actually accepting to work with protective gear, even though it led to discomfort and physical health-related consequences.
The use of protective gear is both a patient safety and an occupational health measure. Yet, it is reasonable to believe that a bad work environment caused by the protective gear can also be a constraint that inhibits protective gear use. Thus, in order to uphold a satisfactory level of patient safety, as well as an acceptable work environment, more attention needs to be given to the demands of protective gear and the ergonomics associated with its use. Although the personnel may accept to work with protective gear that has ergonomic flaws for a while, this adds pressure that in conjunction with other pressures, such as an unacceptable workload, can push the system over the limit. Further consideration also needs to be given to the logistics aspects, which can constrain protective gear use; this is especially the case for mobile forms of care. In this sense, adhering to patient safety pressures (i.e., using protective gear in patients' homes) clashes with the nurses' workload pressures (because it is cumbersome to dispose of the used gear) and with organizational pressures since the logistics involved in having protective gear in place in the patients' homes in itself is demanding.
One trade-off identified in our study that does not fit within the pressures diagram proposed by Sanford et al. (2022) is the trade-off, described above, where managers downgrade social support to their personnel in order to cope with other pressures. Interpersonal relations and socio-emotional work are important aspects of the psychosocial work environment, according to the Demand-Control-Support Model (Escribà-Agüir and Pérez-Hoyos, 2007;Johnson and Hall, 1988;Karasek and Theorell, 1990;Stansfeld and Candy, 2006). They are also important to achieve effective teamwork, since this involves socio-emotional interaction as well (Wheelan, 2005). Thus, while Sanford et al.'s (2022) model primarily focuses on safety, much like Rasmussen's (1997) dynamic safety model, it is desirable to also include socio-emotional pressures. This enables the use of the competing pressures model to also investigate the work dynamics from a work environment perspective. Another trade-off shown in the results that involve socio-emotional work and that does not fit the competing pressures model, is when nurses, despite a high workload, had to help the home care aides they worked with to mitigate their fear of catching Covid-19. Examples of how this can be illustrated as pressures diagrams based on the discussion above, can be found in Figs. 2 and 3.

Key takeaways to achieve a sustainable work environment during a crisis
The work environment is crucial for an organization's ability to handle a crisis in a sustainable and resilient way, especially if the crisis drags out over time. This exploration of the work environment related challenges that home care nurses and home care managers faced during the Covid-19 pandemic provides three key takeaways.
First, social support from management is important in order to increase the personnel's capability to handle a high workload (Johnson and Hall, 1988;Karasek and Theorell, 1990). This was sometimes difficult for the management in the organizations studied because of the pressure to adhere to other needs. Thus, there is a need for a support organization capable of handling some of the pressures experienced by managers during a crisis to decrease the complexity and workload. This would provide them with more time to socially support their subordinates.
Second, the need to communicate instructions to others took considerable effort, especially for managers that had to convey a lot of Covid-19 related information to their staff, but also for nurses to the Fig. 2. Venn diagram illustrating the relationship between six types of pressures including socio-emotional. The illustration shows the trade-offs made by managers including their expressed inability to adhere to their personnel's socio-emotional needs. It also shows that the managers' workloads are too high and that they make personal sacrifices in order to tend to other pressures. home care aides. Effective communication is an important capability when responding to a crisis (Longstaff and Yang, 2008;Steen and Morsut, 2020). Thus, there is a need to study how crisis-related communication can be designed, taking into consideration both the actual information provided, and the communication channels and strategies used.
Third, protective gear use, like other safety routines, involves much more than just compliance. This is because compliance in itself is more complex than one sometimes assumes. Thus, it is also important to consider how to comply, and what complying with one routine means for the work system as a whole (Rydenfält et al., 2013(Rydenfält et al., , 2014. Our results clearly indicate that to comply according to the protective gear guidelines, the personnel trade off their personal needs, and put up with an increased workload. This should be considered when designing protective gear and when formulating routines for its use. One viable approach could be to take the personnel's understanding of how the routine works (i.e., how it protects them) as the point of departure when investigating its use, rather than focusing on their compliance (Rydenfält, 2022).

Limitations
While this is a study of home care nurses and managers, the results apply to home care aides as well. For example, they use the same type of protective gear. Thus, the home care aides can be expected to face the same types of protective gear issues as the nurses. It would have been desirable to also include home care aides and other personnel groups that works close to the patients in the study and we intend to do so in future studies. The competing pressures model, including the pressures diagram, appears to be a useful and novel way to illustrate how work environment aspects interrelate with other priorities and/or pressures in an organization. But this requires more studies and possibly an adaption in line with what we have already suggested: to also account for psychosocial needs in relation to the work environment.

Conclusions
During the Covid-19 pandemic, home care nurses and managers experienced both an increased workload and psychosocial strain. For managers, a major contributor was the increased complexity of the work. There were also challenges associated with changes in organizational practices intended to decrease the transmission of Covid-19. Changes related to reorganization of work, including digitalization, appear to have been less challenging than the changes related to how the care work is conducted, that is, the increased level of protective gear used. Lack of control and support in relation to an increased workload are factors that could have had a negative effect on the work environment on the individual level. On a systems level, our discussion indicates that the results in part could be explained by trade-offs between competing demands that the participants have experienced.
We identify three key takeaways for managing crises in a sustainable manner: 1) to support managers in increasing their ability to provide social support to their personnel, 2) to increase crisis communication preparedness, and 3) to apply a holistic perspective on protective gear use that includes ergonomic and logistics aspects, and not just compliance and its protective power. More studies are required to investigate how this should be done in practice. We also conclude that the competing pressures model, including the pressures diagram, appears to be a viable tool, useful when exploring the dynamics that make up the work environment in complex organizational contexts such as healthcare (Plsek and Greenhalgh, 2001;Sanford et al., 2022).

Fig. 3.
Venn diagram illustrating the relationship between six different types of pressures including socio-emotional pressure. The illustration shows the trade-offs made by home care nurses including their socio-emotional efforts put into mitigating the home care aides' fear of Covid-19 and their own increased workload. As can be see, in this case, the workload is considered to be too high.

Funding
This work was supported by AFA Insurance (grant number: 200137).

Declaration of competing interest
The authors have no known conflicting interests.