The Impact of COVID-19 on Nursing Practice Environments in Mental Health and Psychiatric Units ^†

Abstract

The rapid evolution of the pandemic did not allow for the preparation of different clinical settings. For this reason, the evaluation of the repercussions and the investment in improvement strategies has become important. The aim of this paper was to analyse the impact of COVID-19 on nursing practice environments in Mental Health and Psychiatric Units of three hospitals, through a quantitative observational study. Data collection was carried out through a questionnaire with inquiries on the characterization and the SEE-Nursing Practice. We confirmed a positive impact on the Structure and Outcome components of the nursing practice environments and a negative impact on the Process component.

1. Introduction

Over the last few years, a special interest has emerged in studying professional practice environments and their impact on health professionals, users and families, and healthcare organizations [1,2]. Representing the main workforce in health care, nurses have been on the frontline since the beginning of the pandemic and have experienced a negative impact on their mental health [3,4], whose severity was enhanced by the precarious working conditions, which, in many situations, were already being experienced before the pandemic.

COVID-19 imposed increased challenges on the health system and institutions, including Mental Health and Psychiatric Units, which had to create conditions to respond to the growing population’s health needs. To this end, it was necessary to identify areas with greater weaknesses and adapt management and work processes, requiring a series of individual and organizational strategies [5,6]. Due to the difficulty in hiring nurses, they were mobilized between services, their tasks were changed, and they were overloaded with a high number of patients under their responsibility [7,8,9]. However, despite the high pressure that the pandemic exerted on practice environments, it brought visibility to nurses and nurse managers [5,6,9]. Thus, this study aimed to assess the impact of COVID-19 on nursing practice environments in Mental Health and Psychiatric Units.

2. Material and Methods

A quantitative observational study was conducted in the Mental Health and Psychiatric Units of three hospitals in the northern region of Portugal. About 96 nurses participated in the study, following a non-probability convenient sampling technique. A self-completed questionnaire with inquiries on sociodemographic and professional characterization and the Scale for the Environments Evaluation of Professional Nursing Practice (SEE-NursingPractice) [10] were used as data collection tools. The SEE-Nursing Practice is composed of three subscales: Structure, Process, and Outcome [10]. In data collection, the participants were asked to respond regarding two distinct time periods: prepandemic and after the fourth critical period of COVID-19 in Portugal, with the data collection from 15 August to 15 October 2021. For data analysis, we used the Statistical Package for the Social Sciences (SPSS), version 26.0. In the analysis of the results, the following criteria were established: mean score <1.75—dimension of the practice environment unfavourable to the quality of care; between 1.75 and 2.75—dimension of the practice environment moderately favourable to the quality of care; >2.75 to 3.75—dimension of the practice environment favourable to the quality of care; and >3.75—dimension of the practice environment very favourable to the quality of care. Comparisons between the prepandemic time and after the fourth critical period of COVID-19 were based on the Student’s t-test for two paired samples. The level of significance was 0.05. The study was approved by the ethics committees of the hospital institutions involved.

3. Results

Of the 96 nurses working in Mental Health and Psychiatric Units who participated in the study, 67.7% were female, with a mean age of 42.8 years (SD = 11.3). Regarding marital status, 56.3% were married, 31.3% were single, and 12.4% were divorced. It should be noted that 39.6% of the nurses were working in areas of caring for people with COVID-19.

The results concerning the professional practice environments of Nursing in Mental Health and Psychiatric Units are explained in

Table 1. Mean scores of the components/dimensions of nursing practice environments.

Components/Dimensions	Prepandemic	After the Fourth Critical COVID-19 Period	p-Values *
Structure component
People management and service leadership	3.4	3.6	0.025
Physical environment and conditions for appropriate service	3.0	3.1	0.043
Nurses’ participation and involvement in the institution’s policies and strategies	3.1	3.3	<0.001
Institutional policy for professional qualification	3.0	3.1	0.077
Organisation and guidance of nursing practice	3.4	3.4	0.815
Quality and safety of nursing care	3.6	3.7	0.051
Structure subscale	3.2	3.4	0.001
Process component
Collaboration and teamwork	3.5	3.6	0.048
Strategies for ensuring quality in professional practice	3.3	3.4	0.078
Autonomous practices in professional practice	3.8	3.5	<0.001
Care planning, evaluation, and continuity	3.9	3.6	<0.001
Theoretical and legal support of professional practice	4.0	3.9	0.058
Interdependent practices in professional practice	3.1	3.3	<0.001
Process subscale	3.6	3.5	0.040
Outcome component
Systematic assessment of nursing care and indicators	3.1	3.3	0.002
Systematic assessment of nurses’ performance and supervision	2.8	3.0	<0.001
Outcome subscale	2.9	3.1	0.001

* Student’s t-test for two paired samples.

.

The study findings indicated a positive impact on the Structure (p = 0.001) and Outcome (p = 0.001) components of the nursing practice environments and a negative impact on the Process (p = 0.040) component. After the fourth critical period of COVID-19, the mean of the Structure component increased, with the best scoring dimensions being the ‘quality and safety of nursing care’ (mean = 3.7) and ‘people management and service leadership’ (mean = 3.6). Although there was an increase in the mean score in five of the six dimensions of the Structure component, this increase was only significant in the dimensions of the ‘people management and service leadership’ (p = 0.025), the ‘physical environment and conditions for appropriate service’ (p = 0.043), and ‘nurses’ participation and involvement in the institution’s policies and strategies’ (p < 0.001).

Regarding the Process component, the mean in the dimensions was lower after the fourth critical period of COVID-19, apart from the dimensions of the ‘interdependent practices in professional practice’, the ‘strategies for ensuring quality in professional practice’, and the ‘collaboration and teamwork’. Analysing the impact of COVID-19, the mean score decreased significantly in the dimensions of the ‘autonomous practices in professional practice’ (p < 0.001) and the ‘care planning, evaluation, and continuity’ (p < 0.001).

Regarding the Outcome component, after the fourth critical period of COVID-19, the mean of both dimensions and the subscale itself was higher than in the prepandemic period. Moreover, the Outcome subscale had the lowest score among all the subscales. The dimension of the ‘systematic assessment of nurses’ performance and supervision’ was one of the worst scored dimensions in all the subscales (mean = 3.0).

4. Discussion

The results revealed a positive impact on the Structure and Outcome components and a negative impact on the Process component. However, the three components of the practice environments remained favourable to the quality of care, which was in line with what was found in a study conducted in Portugal [11]. In fact, an investment in structural conditions was observed, with the adequacy of material resources, the hiring of more nurses, and the support provided by health institutions and nurse managers. These strategies were decisive in ensuring the focus of the teams on providing quality and safe care, which justified the increase in the mean score in the Structure subscale, which agreed with the results of other studies [9,11,12,13]. The dimensions of the ‘institutional policy for professional qualification’ and the ‘physical environment and conditions for appropriate service’, retained low scores in both periods, demonstrating the need for investment in these areas. Moreover, in the Structure component, it is noteworthy that the dimension of the ‘people management and service leadership’ obtained a higher score after the fourth critical period of COVID-19, which may be justified by the greater support provided by nurse managers to the nurses in their team, which was also observed in another study [12].

Regarding the Process component, the impact tended to be negative, except in the dimensions of ‘collaboration and teamwork’ and ‘interdependent practices in professional practice’. Given the unpredictability of the pandemic situation, teamwork allowed for synergies, which enhanced the provision of more effective care [11,13].

In the Outcomes component, after the fourth critical period of COVID-19, the mean in both dimensions and the subscale itself was higher than in the prepandemic time period. However, these dimensions had the lowest scores, pointing to the need for continuous monitoring of nursing indicators and the adoption of an institutional policy that values nurses’ performance and supervision. In fact, it is not enough to invest only in structural conditions, as only with the systematic assessment of nursing care and indicators will it be possible to ensure the quality of the processes implemented in response to the challenges imposed by the pandemic [13]. The systematic evaluation of nurses’ performance and supervision, the institutional policy for a professional qualification, and the physical environment and conditions for the operation of service were the worst scored dimensions, reinforcing the priority of investment in these areas.

5. Conclusions

Focusing on the impact of COVID-19 on practice environments in Mental Health and Psychiatric Units, this study provided important information for the prioritization of strategies promoting positive professional environments in these care areas. The systematic evaluation of nurses’ performance and supervision, the institutional policy for professional qualification, and the physical environment and conditions for the operation of service were the worst scored dimensions, reinforcing the need for investment. Nurse managers can make a difference by creating safe and healthy environments, contributing to a greater commitment of nurses to their profession and the healthcare institution. Although public recognition can add value and purpose to the nursing profession, organizational support and effective leadership from nurse managers are imperative for promoting positive nursing practice environments in Mental Health and Psychiatric Units.