Behind the masks: Fear, guilt and solitude in Belgian retirement homes during the COVID-19 pandemic

“You could feel the atmosphere in each retirement home almost immediately upon stepping through the doors – a feeling of fear, uncertainty, and solitude, but also positivity and strong determination to help amidst this crisis.” Sofie Spiers, the project medical referent of MSF’s COVID-19 response in Belgium was part of the mobile teams providing urgently needed psychological first aid to residents and staff in long-term care facilities in Flanders from early April.

Putting older people and those with existing medical problems at severe risk, the unprecedented COVID-19 pandemic forced many retirement and nursing homes into implementing strict confinement and isolation early on.

Yet the Belgian health system had only partially prepared care facilities to respond to an infectious respiratory disease outbreak of a global scale, and offered only limited support to face the mental health challenges lurking behind staff’s and residents’ facemasks.

After initially reinforcing hospital capacities in Antwerp, Charleroi and Mons, MSF teams started supporting several retirement homes in Brussels from mid-March, and in Flanders and Wallonia from early April. In many of these facilities, working and living conditions had deteriorated quickly.

Strict confinement measures and fear of overburdening hospitals meant COVID-19 patients could not always be seen by their doctors and did not receive palliative care.

The staff we spoke to often felt overwhelmed and powerless.
Sanne Kaelen, psychologist with MSF’s COVID 19-project in Belgium

A lack of official guidelines on how to handle suspected infections and protect residents and staff led to confusion and uncertainty. Caregivers were often missing essential personal protective gear or unsure how to correctly use it, and feared to risk infecting themselves and their residents.

“At first, we concentrated on setting up isolation measures and training caregivers and cleaning personnel on hygiene, prevention, and safe procedures for testing. From the beginning talked to staff about fears, stress, and resilience, and quickly realised there were pressing emotional and psychosocial stressors at play”, recounted Sofie.

For caregivers and nursing staff, grief over lost residents mixed with a sense of guilt and anxiety for risking transmitting the disease or contracting it. Many felt defenceless due to missing protective equipment, and experienced stress and exhaustion due to intense work schedules and the fast-evolving pandemic situation.

“The staff we spoke to often felt overwhelmed and powerless”, said Sanne Kaelen, the psychologist with MSF’s COVID 19-project in Belgium. “For many, the residents are like family, and their solitude and despair touched them deeply. Seeing some of them stop eating, sleepless and maybe even depressed deeply touched and disturbed them”, she added.

Deploying nine mobile teams with a nurse and health promoter in each, MSF visited 82 retirement homes and long-term care facilities in Brussels and 68 in Wallonia and Flanders in April and May.

Present onsite, these teams gave caregivers a much needed opportunity to voice their emotions, ran group sessions, and offered training on stress management, peer support techniques, and coping mechanisms. From mid-May, the project focus shifted fully to providing mental health support to staff in retirement homes.

“Often, our staff group sessions were the first time care teams were able to sit together and share their fears and coping strategies. Both staff and residents showed great resilience, and it was amazing to see how well people coped despite the stressful situation, but some also experienced sleeplessness, had nightmares, and suffered traumatic stress”, recalls Sanne.

For those staff in need of additional psychological help, MSF offered individual counselling or referred them to a specialist.

On a grey morning in mid-June in a public retirement home in the south of Brussels, a group of caregivers is once again meeting up with an MSF team. Now that fewer COVID-19 cases are reported in most European countries, MSF’s intervention in Belgium is coming to a close.

Today’s meeting is a focus group discussion and part of an MSF-led operational research study pinpointing the major gaps in mental health care during the pandemic.

“We are conducting over 60 in-depth-interviews with residents and several focus groups with staff in eight retirement and nursing homes in Brussels, including public, private, and non-profit institutions”, explained operational research advisor Wilma van den Boogaard.

“Our focus is on how residents and caregivers perceived and experienced the pandemic and confinement, what helped them cope with fear and stress, and what crucial support they were missing”, she added.

For the complex and sensitive subject of mental health, the qualitative research approach offers a clear methodological edge.

“In in-depth interviews and closed focus groups, our research teams are able to create the respectful environment and necessary intimacy to explore deeply personal experiences as well as collective fears. As researchers, we then take a step back, extract major themes and relate them to more structural issues in homes or the overall health system”, said Umberto Pellecchia, the qualitative research advisor supporting the study.

With interviews and group discussions scheduled over the coming weeks, preliminary study results are expected by the end of July and are set to feed straight back into improving mental health support and health policy in retirement homes during outbreaks in Belgium and beyond.

You could feel the atmosphere in each retirement home – a feeling of fear, uncertainty, and solitude, but also positivity and strong determination to help amidst this crisis.
Sofie Spiers, project medical referent of MSF’s COVID-19 response in Belgium 

The Brussels Public Health Institute and the Belgian National COVID-task force are supporting the research project as study partners, and the results will be presented to nursing homes, care providers, and the residents.

“What we hear from staff and residents is often distressing”, said medical referent Sofie, who is now also leading the study as principal investigator.

“But our presence in the retirement homes and our collaboration with national and regional authorities put us in a strong position to improve outbreak preparedness and mental health services, and make a true difference for residents and staff”, she added.