Working Conditions and Practice Adaptations among Nurses and Midwives During the COVID-19 Pandemic in Huambo, Angola: A Mixed-Methods Study
This convergent mixed-methods study of 309 nurses and midwives in Huambo, Angola, reveals that while pandemic adaptations were heterogeneous and centered on biosafety, they occurred amidst severe resource shortages, uneven institutional support, and significant psychological strain, highlighting critical priorities for future workforce preparedness.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
When a public health emergency strikes, the people who keep a society healthy are the nurses and midwives. These are the professionals who stand closest to patients, administering care, monitoring vital signs, and offering comfort. But when a virus like SARS-CoV-2 spreads rapidly, the rules of their daily work change instantly. They must protect themselves from infection, reorganize how they move through hospitals, and often do more with fewer supplies. The question of how they manage these sudden shifts is not just about medical logistics; it is about the human capacity to adapt when the systems they rely on are stretched to the breaking point. Understanding this experience is crucial because a health system is only as strong as the people who run it. If those people are unsupported, under-resourced, or overwhelmed, the entire system risks failing the very people it is meant to serve.
In the central highlands of Angola, a team of researchers set out to understand exactly how nurses and midwives navigated the COVID-19 pandemic. They focused on Huambo, a province with a population of nearly 2.7 million people, where the health system had already been rebuilding for decades after a long civil war. The researchers wanted to move beyond simple statistics to see the full picture of what happened on the ground. They asked 309 health workers to look back at their experiences during the pandemic, combining written surveys with open-ended stories. This approach allowed them to see not just how many people lacked equipment, but how that lack changed the way they practiced their profession. The study, conducted between late 2024 and late 2025, reveals a story of profound adaptation, where professionals constantly reshaped their work to fit a reality that was often unpredictable and uneven.
The most striking finding is that the pandemic did not create a single, uniform experience for everyone. Instead, the workload and organization of care changed in different, sometimes opposite, ways depending on where a worker was stationed. For some, the pandemic meant a crushing increase in demands. They reported working double shifts, caring for larger groups of patients with fewer colleagues, and spending extra hours just to finish their daily tasks. In these settings, the pressure was intense, and the need for personal protective equipment was urgent. Yet, for others, the experience was surprisingly different. Some workers described shifts that were shortened or a decrease in patient numbers, which paradoxically gave them more time to focus on individual care. This contrast suggests that the pandemic did not simply add weight to everyone's shoulders equally; it rearranged the entire landscape of work, creating pockets of extreme overload alongside pockets of reduced activity.
A central theme in the stories told by these workers was the sudden and total transformation of safety practices. Before the pandemic, using protective gear was often reserved for specific, high-risk situations. During the crisis, it became a constant, non-negotiable part of every interaction. Nurses and midwives described a new rhythm to their day, where hand washing, wearing masks, and keeping distance were woven into every step of patient care. This shift went beyond just putting on a mask; it changed how patients moved through the hospital and how care was delivered. In maternity wards, for instance, the need for strict hygiene altered the intimate nature of childbirth, with masks becoming mandatory for both mothers and staff. The researchers found that this focus on safety became the organizing principle of their work, even when the physical tools to support it were missing.
The availability of those tools, however, was a major source of stress and inconsistency. The study found that nearly half of the participants said they did not have access to mechanical ventilators, and more than 40 percent reported a lack of oxygen equipment. Personal protective equipment was unavailable for nearly 30 percent of the workers at some point. This created a difficult situation where professionals were expected to follow strict safety protocols without always having the necessary gear to do so safely. The researchers noted that having training on how to use protective equipment did not automatically mean that the equipment was there to be used. This gap between knowing what to do and having the means to do it was a recurring challenge, highlighting that preparation involves more than just education; it requires reliable supplies.
The support provided by employers was another complex layer of the experience. It was not a simple case of an employer either helping or not helping. Instead, support came in a mix of forms that did not always align. A hospital might provide excellent psychological support and training while failing to pay risk allowances or provide transportation for staff. In some cases, workers received adequate protective gear but faced delays in their salaries. This multidimensional nature of support meant that a worker could feel cared for in one aspect of their job while feeling abandoned in another. The study also uncovered darker aspects of the work environment, including reports of workplace violence, where staff faced aggression from patients or family members who did not believe the virus existed. Additionally, a small number of workers reported continuing to work while infected, sometimes under the threat of losing their jobs, pointing to a culture where staying on the job was not always a choice.
Despite these challenges, the health workers in Huambo demonstrated a remarkable ability to adapt. They reorganized their teams, adjusted their schedules, and found ways to maintain care even when resources were scarce. The researchers concluded that the pandemic experience in this region was defined by this continuous, uneven adaptation. It was not a story of total collapse, nor was it a story of smooth success. It was a reality where professionals navigated a shifting terrain of material shortages, organizational gaps, and intense personal fear. The findings suggest that future plans for health emergencies must account for this complexity. Preparedness cannot rely on a single solution, such as just training staff or just stocking supplies. Instead, it requires a coordinated approach that ensures reliable resources, flexible staffing, and comprehensive support that addresses the many different ways a health worker's life and work can be affected. The resilience of these nurses and midwives was evident, but the study makes clear that resilience should not be the only strategy; the systems around them must be built to support them, not just to survive them.
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