The devastating impact of the COVID-19 pandemic on residential care for older persons was
a topic of discussion during a recent meeting of Devon care home owners, researchers and
educators. Locally and globally, the pandemic had a particularly catastrophic impact on
older adults in residential care and their families and friends. Care-givers and care
leaders were also significantly impacted negatively as they struggled to deliver care
and support in uncharted and most challenging circumstances. It has been argued that our
societal failure to learn lessons from previous pandemics leads to failures which
‘should be understood as moral failures that offer moral lessons’.[1] Our aim in this
Editorial is to stimulate discussion regarding the moral lessons that follow from
failures upon the residential care sector during the COVID-19: What have residential
care leaders learnt from their experience of the pandemic? What might educators and
researchers contribute to support the social care sector prepare for future
pandemics?A report from Amnesty International ‘As If Expendable[2]; detailed a raft of failings in the
United Kingdom administration that contributed to the deaths of care home residents.
Between 2 March and 12 June 2020, 18,562 residents died from COVID-19, amounting to 40%
of all deaths. Failings included: ‘mass discharges from hospitals into care homes of
patients infected or possibly infected with COVID-19’; failure to advise or provide
personal protective equipment (PPE) to care homes; failure to ‘assess care homes’
capability to cope with and isolate’ people infected and lack of support to respond to
emergency situations; failure to provide regular testing of care home residents and
staff; ‘imposition of blanket Do Not Resuscitation (DNAR) orders on many residents’; and
suspension of regulatory activity designed to provide protection for care home
residents, for example, from the Social Care Ombudsman and the Care Quality
Commission.[2]Readers of this journal will be acutely aware of the tension which exists, during a
pandemic, between public health ethics which is necessarily focused on population health
and care ethics and human rights perspectives which focus on individual persons. The
failings listed above do not then fully capture the human cost of pandemic restrictions
on care home residents’ relationships with families and friends. A recent paper by
Clayton O’Néill[3]
does just this by detailing the story of ‘Janet’ which brings to the fore the suffering
of care home residents deprived of meaningful contact with loved ones. Janet’s story
details a happy pre-pandemic life with regular visits and outings with a loving niece to
a pandemic existence when ‘she lost her grip on life and the purpose of life […] a life
‘without love unforgiving in its brutality’.[3] As Arthur Frank writes:Stories animate human life; that is their work. Stories work with people, for
people, and always stories work on people’. Stories affect
‘what people are able to see as real, as possible, and as worth doing or best
avoided[4]The stories shared during our meeting in Devon regarding care home leaders and their
experiences of the COVID-19 pandemic were wide-ranging, most predominantly referring to
the selfless dedication and efforts of care home staff to protect residents. One care
home owner shared the devastating impact of residents’ deaths and of the importance of
care home leaders ‘rolling up our sleeves’ enacting a ‘determined, confident and strong
approach’ and showing the team that, despite the significant challenges, there remained
much to be proud of. Another care home owner highlighted the importance and positive
impact of nurses ‘taking a stand’ during the pandemic. Their discerning and cautious
approach to only admit people from hospital (for example, with negative Covid-19 tests)
helped result in fewer infections and deaths than in some other care homes:‘The conflicting advice given by government suggesting that Covid wasn’t likely
to be infectious to older people - and that it was safe to admit infected people
brought into the homes from hospital - was farcical. Anyone who is infections
from an air borne virus will potentially spread it to others, unless significant
measures (beyond those available in a non-hospital setting) are in place. Why
were social care homes pressured into doing this? And why did the nurses accept
this pressure as being OK? Nurses in the Health, Social Care and Governmental
and regulatory bodies should go back to the established evidence before acting
upon contradictory pandemic guidance geared to protecting the NHS, seemingly
having priority. Yes, they could have stepped up and said ‘no’, not unless the
correct protections and comprehensive measures were put in place (but which were
not available). One must question whether systemic adherence to contradictory
guidance was reasonable or was it due to a lack of education, and/or seemingly
having to go against their better instincts?’The stand taken by care home leaders in our discussion group was courageous and
praiseworthy, particularly at a time when there was much uncertainty and pressure to
support hospital discharges. There have, then, been positive achievements regarding care
home leaders innovative responses to adversity.Arguably there were also missed opportunities for nurses, and other care leaders, to have
done more to enact advocacy and allyship in relation to older people, rather than follow
contradictory guidance. Arguments suggest an ‘(over-) heroization’ of nurses’
work[5]
calling into question nurses’ commitment and ability, during the pandemic, to enact
social justice. Whilst there is evidence of supererogatory efforts of many nurses
working with older adults, there is also anecdotal evidence of insensitivity and
possible abuses of power which increased the suffering of older people and their loved
ones in following such guidance.The moral lessons that follow from moral failures require open and honest engagement from
key stakeholders. They require a slow approach characterised by, among other elements,
the enactment of ethical sensitivity, a commitment to solidarity and engagement with
stories.[6]
They include also making space to plan and operationalise practice-based strategies that
put older people and their loved ones first and innovative educational approaches which
prioritise the cultivation of character in care. To that end, we are collaborating in
the development of a Massive Open Online Course (MOOC) on this theme which will be
available in early 2023.The moral failures upon residential care have been framed as violations of human rights.
As O’Neill [3] writes:‘…the rights of residents in care homes were not protected with appropriate care,
caution, courage and concern. Whilst there was a need to protect life and the
restrictions on visitation might have been justifiable, for the most part,
individual autonomy was not upheld sufficiently. That is not something of which
we can be proud.’The first article in this issue details the moral failures experienced in residential
care, in a European country, during the pandemic and efforts made to strengthen the
moral community of older persons needing care, their care partners and professional
care-givers.[7]Regarding the contribution of educators and researchers to support the social care sector
to prepare for the next pandemic – and there will be future pandemics – we agreed that a
focus on virtue and care ethics perspectives are critical at a local, national and
international level. There needs to be pride in care practices, courage and practical
wisdom in leadership and serious engagement across the Health and social care system
with previous failures, with a commitment to do better in future. Critically, there
needs to be a mobilisation of the sector to effectively pressurise politicians and
regulators to plan now so the same failures are not repeated. The lessons we need to
learn include being proactive in creating meaningful collaborations to listen to and
include the voices of residents, their loved ones, care-givers, care providers and care
sector leaders, educators and researchers. Collaborations which will lead to innovative
strategies to ensure as far as possible that, in the next pandemic, there will be no
‘Janet’s’ and all receive the system support, love and care they deserve.