Introduction
Residents of care homes across the globe are affected by the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), referred to as COVID-19 or Corona in public discussions, in several detrimental ways. Firstly, medical experts internationally describe them as a high-risk group due to higher mortality rates among COVID-19 patients aged 70 years and older (Bonanad et al., Reference Bonanad, Gracía-Blas, Tarazona-Santabalbina, Sanchis, Bertomeu-Gonzáles, Fácila, Ariza, Núñez and Cordero2020; Gosch et al., Reference Gosch, Singler, Kwetkat and Heppner2020). Secondly, in an effort to protect residents in care homes from contracting COVID-19, strict contact bans were imposed for care home residents in March 2020 (Rothgang et al., Reference Rothgang, Domhoff, Friedrich, Heinze, Preuss, Schmidt, Seibert, Stolle and Wolf-Ostermann2020). Thirdly, the public and political focus on older people as particularly vulnerable has had consequences to social images of ageing and old age (e.g. Ayalon et al., Reference Ayalon, Chasteen, Diehl, Levy, Neupert, Rothermund, Tesch-Römer and Wahl2021), that have led to discrimination (Graefe et al., Reference Graefe, Haubner and van Dyk2020) and influenced how generational groups relate to each other both in positive (e.g. providing support) and negative ways (e.g. marginalisation) (Oswald, Reference Oswald2020). Viewing older people as a vulnerable group and enacting measures to protect them can, however, increase their vulnerability. Long before COVID-19, empirical evidence clearly showed that social isolation of older people, particularly with existing physical and mental deterioration, is strongly associated with anxiety, depression, general health deterioration and ultimately decreased life expectancy (Spitzer, Reference Spitzer2018). Thus, current measures of protecting older people by reducing the amount of contact they have with significant others as well as reducing their mobility (see the Care homes in Germany section) has the capacity to increase their risk of loneliness (Seifert and Hassler, Reference Seifert and Hassler2020), poor health and mortality rather than reduce that risk (Fischer et al., Reference Fischer, Raiber, Boscher and Winter2020). As Schulz-Nieswandt (Reference Schulz-Nieswandt2020) has argued, the pandemic threatens to erase the milestones achieved in the past two decades on providing care in residential settings that goes beyond physiological health and hygiene, and sets its focus on residents’ rights to personal freedom and participation. However, there are rarely suggestions on how to address negative effects.
The far-reaching interventions by many governments to limit the transmission of the virus and to prevent overburdening of health-care systems have affected social orders on several interconnected levels: medical, political, economic, cultural and social. Given the ongoing crisis, researchers outside epidemiology and medicine have pointed to the need to not only identify the social effects of these measures and the serious consequences for populations and communities but also to provide approaches for understanding the underlying social mechanisms (Pfaller, Reference Pfaller2020; Schulz-Nieswandt, Reference Schulz-Nieswandt2020): ‘Thus, instead of understanding social conditions as mere “secondary effects” of necessary medical practices of protection, sociology is able to describe and analyse these effects regarding their inherent cultural significance and “social reality”’ (Pfaller, Reference Pfaller2020: 822). For the purpose of gaining insights into the social reality of care homes during the early phases of the pandemic, we would add that inter-disciplinary perspectives from sociology, developmental psychology and environmental gerontology are needed. Rising infection rates in autumn 2020, a second ‘lockdown’ across many European countries as well as discussions of how to provide ‘focused protection’ for vulnerable groups underpin the need for differentiated and evidence-based analyses to the first responses to the crisis.
Multiple perspectives
To enable an inter-disciplinary perspective, the following three conceptual lenses are used to provide a framework in which to gain an in-depth understanding of residents’ experiences during the early phase of the pandemic. This includes an environmental lens on ageing that considers the role of agency and belonging in relation to physical and social places in older people's lives; a resilience lens on ageing that examines the way experiences made across the lifecourse come into play when dealing with new challenges; and thirdly, a gendered lens on ageing, with the aim of rendering visible experiences of ageing and living in a care home that are easily overlooked when acute problems affect everyday life and obscure existing inequalities.
Environmental lens on ageing
To address the reality of living in a care home during the early phase of the pandemic, the relationships between ageing individuals and their environments and how these relationships shape developmental outcomes such as wellbeing, autonomy and health need to be considered. From an environmental gerontology perspective, the focus is on processes of agency and belonging as two key aspects of older adults’ place relationships (Oswald and Wahl, Reference Oswald and Wahl2019). Following Bandura (Reference Bandura2006), agency refers to the process of becoming a change agent in one's own life by means of intentional and proactive behaviours imposed on the physical–social environment. The focus of agency lies in actively making use of the objective physical–social environment, including acts of using, compensating, adapting, retrofitting, creating and sustaining places. In contrast, belonging incorporates all non-goal-oriented cognitive and emotional aspects that make a space a place, the subjective and emotional evaluations and interpretations of places, as well as processes of attachment to places over time. That is, belonging reflects the experiential connection of attachment and bonding with the physical environment (e.g. home as a refuge, personally meaningful objects), the social environment (e.g. family members, community of people) and their intersection (Rowles, Reference Rowles, Rowles and Ohta1983). Whereas spatial agency is assumed to decrease from middle to late adulthood, place attachment and belonging is considered to increase. However, within environmental gerontology, there have been calls for a more fine-graded situational perspective of spatial agency and belonging in older adults’ everyday lives (Chaudhury and Oswald, Reference Chaudhury and Oswald2019). An environmental gerontology perspective can inform understandings of how spatial agency and belonging evolve dynamically across the lifecourse, but also how they may change during the experience of a pandemic in a care home, and potentially impact on multiple domains of everyday life.
Resilience lens on ageing
Psychological resilience refers to a stable trajectory of mental health despite exposure to serious stressors or the capacity to return to equilibrium of mental health after a traumatic event (Chen and Bonanno, Reference Chen and Bonanno2020). Thus, vulnerability is often juxtaposed by the concept of resilience. In developmental psychology, resilience is understood as an intra-personal resource that is built and developed over the course of a lifetime. From this vantage point, research on resilience is not only concerned with how extreme risks and adverse circumstances are overcome, but how individuals are capable of maintaining or returning to self-worth and sense of agency, a process Fooken (Reference Fooken and Maercker2009) has described as ‘post-traumatic growth’. Resilience in later life has been defined and empirically proven (e.g. the Berlin Aging Study) as a relational concept of exchange between personal and environmental conditions, risks and resources, either based on internal or external interventions (e.g. Staudinger et al., Reference Staudinger, Freund, Linden, Maas, Baltes and Mayer1999; Staudinger and Greve, Reference Staudinger and Greve2001). Facing challenges in the face of the COVID-19 pandemic, Chen and Bonanno (Reference Chen and Bonanno2020) recently put together existing evidence on several promoting factors, including individual as well as social, interpersonal and contextual aspects. Among them are optimism, social support and bonding, staying open-minded and informed without over-consuming media coverage, employing distraction strategies and reducing social isolation through online communication (Bonanno, Reference Bonanno2020). In addition, predictors of resilience as an outcome include exposure severity (circumstances of the acute or chronic adverse event), family context and community characteristics (Bonanno, Reference Bonanno2020). A resilience perspective on ageing in care institutions during the current pandemic can help to identify individual resources and risks to cope better with the pandemic and possibly to provide more resilient future care environments.
Gendered lens on ageing
Care homes are often considered a domain of women, both in terms of who lives there, who provides the care and how care is organised (Sutherland et al., Reference Sutherland, Ward-Griffin, McWilliam and Stajduhar2016). In addition, women's higher life expectancy and their quantitative majority in the 75+ age group (Eurostat, 2019) (80+ for Germany; GeroStat, 2020) has contributed to a view in which old age is seen as an experience of women (Backes, Reference Backes1997). This has created a blind spot in which shifting gender relations, both in quantitative terms (e.g. men growing old and moving into care homes) and qualitative terms (e.g. changed images and experiences of ageing and gender due to structural and cultural changes) are easily overseen (Leontowitsch, Reference Leontowitsch, Denninger and Schütze2017). Feminist research and later gender theories have deconstructed the categories of ‘woman’ and ‘man’ by conceptualising them as social constructions (West and Zimmerman, Reference West and Zimmerman1987) and acknowledging the great diversity among women and men as well as other genders and how they are affected by further social categories of difference, such as ‘race’, class, ethnicity, age, health and sexual orientation (Ray, Reference Ray1996; Calasanti and Slevin, Reference Calasanti and Slevin2001). The need to consider the interconnections of gender and age(ing) along these structural advantages and disadvantages should, following Krekula (Reference Krekula2007), not be added together to multiple disadvantages, but rather understood as dynamic interactions:
The interplay between power relations can signify that these structures either strengthen or weaken each other, that they supplement or compete. The intersection may signify the construction of new forms of marginalization, or a mutual neutralization of each other. (Krekula, Reference Krekula2007: 167, italics in the original)
Thus, using a gendered lens on ageing in care institutions with COVID-19 calls ‘attention to the different social and symbolic worlds of age and ageing in which men and women reside’ (Levy, Reference Levy1988: 484). In this article, we use a gendered lens on ageing not to compare the experiences of men and women in care homes but to render visible the mechanisms that shape their experiences in light of and despite the pandemic.
The aim of this research is to understand the social reality of living in a care home during the early phase of the pandemic. In doing so, the study set out to investigate (a) how older people spent their day in the context of isolation in care homes, (b) what past events helped them in coping with the pandemic, and (c) what their perspectives for the future were.
Care homes in Germany during the spring of 2020Footnote 1
To ensure the safety of care home residents from infection with SARS-CoV-2, a contact ban was put into place in Germany in early March (Fischer et al., Reference Fischer, Raiber, Boscher and Winter2020). As in many other European countries, this involved no visits from family members or friends, no contact with other residents, little to no movement within the care home building by residents, and staff wearing full protective clothing. Given the scale of these measures, care home managers, staff, professional bodies, family members of residents, and residents themselves called for regulations to be loosened. A joint Statement by the Sections for Geriatric Medicine (II), Social and Behavioural Gerontology (III), Social Gerontology and Working with Older People (IV) of the German Gerontology and Geriatrics Society in April called for measures to be reviewed regularly and to ensure that the protection of residents did not eliminate their rights to personal freedom and participation (DGGG, 2020). In particular, the letter rejected any isolation of residents to their rooms and highlighted the risks of social distancing rules on residents’ mental and physical health (DGGG, 2020). Given the federal structure of political decision-making in Germany, the responsibility for public health lies primarily with intermediate and local public health authorities in 16 federal states and approximately 400 districts (including 107 ‘district-free’ cities). They adapt the national guidelines and recommendations to local needs. Thus, measures taken to avoid the spread of the virus varied and continue to vary between the federal states (Rothgang et al., Reference Rothgang, Domhoff, Friedrich, Heinze, Preuss, Schmidt, Seibert, Stolle and Wolf-Ostermann2020). However, in the early stages of the pandemic the contact ban in care homes was similar across Germany. Some regions were particularly affected by high numbers of infections in some care homes and subsequent fatalities during March and April 2020. This contributed to providing increased protection to older people in care homes across the country. COVID-19 patients returning to care homes after treatment in hospital had to undergo quarantine in an isolation area for 14 days.
The data presented in this paper were collected in two care homes in Frankfurt am Main, which is geographically located in the south of the state of Hesse. In Hesse, visits by persons belonging to the following groups were not affected by the contact ban: pastoral care, lawyers, dedicated persons handling a resident's legal affairs, relatives of residents in the process of dying and specialist staff providing palliative care (Hessische Landesregierung, 2020). The first phase of easing measures in the state of Hesse was introduced on 4 May, allowing residents one visit per week for up to one hour by a close relative or friend wearing a mask and keeping 1.5 metres distance in a communal area with no physical contact. Depending on the individual risk assessment plan of each care home, there could be variations between settings (e.g. 30-minute visits instead of one hour), but the minimum of one visit per week was to be allowed. A ban on visits could only be enforced by local health authorities, which could order homes to self-isolate if there was an outbreak in the area or within the home itself. The second phase of easing regulations in Hesse was issued on 22 June, increasing visits from one to three per week and keeping to hygiene rules. These regulations were confirmed on 1 and 29 September 2020. However, due to increases in infection rates in certain regions of Hesse in September and October some residential care homes were forced to reduce social contacts.
Methods
Access to residents in care homes during the second phase of restricted visiting was only possible due to the collaborative work of the Frankfurt Forum of Interdisciplinary Ageing Research (FFIA). The forum brings together scientists from different disciplines to gain funding and undertake inter-disciplinary research on ageing and later life. One of these projects is the DAVOS study, which is a large intervention study on improving the treatment of depression among residents in care home settings by an innovative and stepped structural case management programme (Tesky et al., Reference Tesky, Schall, Schulze, Stangier, Oswald, Knopf, König, Blettner, Arens and Pantel2019). Among other objectives, it measures and monitors the mental health of residents across ten care homes in Frankfurt am Main and works closely with dedicated care staff who are trained as depression case managers and liaise between the research staff, the residents, psychotherapists and medical practitioners. When care homes closed to visitors and (external) research staff (including psychotherapists) in mid-March 2020, data collection by project staff as well as all intervention modules had to be paused. As a result, alternative methods of data collection were included, such as phone interviews by external researchers, and the depression case managers were trained in collecting data. During FFIA meetings, the possibility of collecting data on this novel and worrying situation of residents during the pandemic was discussed. A team of researchers from sociology, psychology and medicine was formed with the aim of investigating the experiences of care home residents as directly as possible under the given circumstances. Two of the care homes involved in DAVOS were chosen for this purpose. The respective depression case managers who were members of the internal nursing home staff and hence had direct access to the residents agreed to additional data being collected around the end of May. Both care homes are located centrally in Frankfurt, one is part of a large national ecclesiastical non-profit corporation (care home A), the other care home is part of a municipal trust (care home B). Care home A has 73 residential care places and 53 independent living units, whereas care home B has 123 residential care places in single-occupancy rooms. At the time of data collection, care home A had 122 residents and care home B had 120. These two care homes were chosen for the current study as the depression case managers who were to collect the data had proven particularly dedicated in the DAVOS study. In addition, both care homes had not had any cases of COVID-19 thus far. There were no significant differences between the two homes in terms of residents’ age or severity of depression symptoms at baseline. Care home A had a higher proportion of women (87.5%) than care home B (50.0%). Data were collected in care home A from 8 to 15 June and in care home B from 5 to 10 June. These two care homes are part of a large infrastructure of municipal and independent trusts providing care services for an increasingly heterogeneous ageing population in Frankfurt am Main.
Ethics
The DAVOS study received ethical approval by the ethics committee of the Medical Faculty of the Goethe University Frankfurt in 2018. As the data collection of the present sub-study was incorporated into data assessments by the DAVOS depression case managers, it is covered by the same ethical approval. Participants of the present sub-study are a sub-sample of the DAVOS study population and had given written informed consent before entering the DAVOS study. In addition, they were informed about the involvement in the sub-study, duration of interview and data handling, and consented verbally. In line with European data management guidance and local regulations (Data Protection and Freedom of Information Act of Hesse, HDSIG), the data were anonymised, and the paper versions of the interviews are stored in a secure filing cabinet at Goethe University. It is not possible to trace residents’ identity from the documents developed during data analysis.
Data collection tool
A semi-structured paper-and-pen questionnaire with open-ended questions was developed around three topics: Part 1 asked about the current situation and the daily life of participants; Part 2 asked about the participants’ past and how past events related to their current situation; and Part 3 asked about the future both with and beyond COVID-19 (Table 1). The final section collected information on age, gender, familial status, education and entry date to the care home.
Table 1. Interview schedule
Residents could either fill in the answers themselves or have their responses noted down in a face-to-face session by the DAVOS case managers (one in each care home), who had received advice in conducting the questionnaire via phone sessions. Having data collected through third-party interviewers forces researchers to relinquish control over the data collection process (Maynard and Schaeffer, Reference Maynard, Schaeffer, Maynard, Hourkoop-Steenstra, van der Zouwen and Schaeffer2002). This means that no real insight is available as to who was asked to be interviewed and who was not or what criteria the two case managers used to select potential participants and how their tacit knowledge of the care home and its residents co-created the data collected (Schaeffer and Maynard, Reference Schaeffer, Maynard, Holstein and Gubrium2003). Despite these limitations, this approach enabled the inclusion of residents who would not have been able to fill in the form themselves. Thus, it is in line with participatory approaches in social research that aim to include people often excluded from research and to capture their experiences rather than rely on others to talk on their behalf (Leontowitsch, Reference Leontowitsch and Leontowitsch2012). The returned questionnaires show that the care staff interviewers wrote down the responses verbatim without paraphrasing, and that participants felt free to express themselves in quite candid ways (see the Findings section) which adds to the quality of the data.
Participants
A total of 22 questionnaires (eight from care home A and 14 from care home B) were returned to the research team. Three had been filled in by participants themselves (occupants of independent living units within care home A) and 19 had been filled in by proxy. In terms of age, participants ranged from 61 to 100 years of age with a mean age of 84 years. The participants’ depression score measured on the Geriatric Depression Scale (Yesavage et al., Reference Yesavage, Brink, Rose, Lum, Huang, Adey and von Leirer1982) at baseline (2019) and in June 2020 were taken from the DAVOS primary outcome assessments and indicate an increase in mild depression (from mean = 5.50, standard deviation (SD) = 3.54 at baseline to mean = 6.54, SD = 4.14) during the early phase of the pandemic. The participants included seven men and 14 women, with one participant not providing any information on gender, familial status and education. Apart from depression, none of the participants were living with dementia or other significant psychiatric disorders since these were exclusion criteria for participation in the DAVOS study. Further exclusion criteria were addictive disorders, severe mental illness and not being able to give informed consent. An overview of the participants’ characteristics has been provided in Table 2.
Table 2. Participant characteristics
Data analysis
The data collected differed from typical semi-structured interview data, as the responses were shorter than those usually given in interviews where responses are not written down and where interviewers can encourage interview participants to talk more using non-verbal and verbal cues. Responses were phrased in short sentences, with variations from one to nine sentences provided per question. Moreover, in some cases the responses were fragmented and brief, which can be explained by the fact that 19 responses were written down by care staff. Despite these limitations, rigorous analysis of answers to open-ended questions gathered in a structured interview process can enrich the understandings of people's perceptions, attitudes and experiences. In response to these issues, template analysis was used to conduct a thematic analysis of the responses to the open-ended questions of the structured interview guide. Template analysis is an established method of analysing a wide range of textual data and allows a pragmatic approach to data that can vary in length and detail (Cox, Reference Cox, Thorpe and Holt2008; King, Reference King, Symon and Cassell2012).
Template analysis involves the development of a coding template, which summarises themes identified in a dataset and organises them in a meaningful and useful manner. In this study, initial themes were identified by reading responses across the dataset by all four researchers. The collection of themes (the template) was then used to analyse all the data in a more in-depth reading process. During the reading and analysing process, the template was modified as new themes emerged, and some were merged with other themes. This process continued until the final template was used on all the data. The themes were agreed by the team of researchers with ML applying a gendered lens to the analysis. The relatively strong link between the initial template and the final themes in this project was not unexpected as the questionnaire had three topics – daily life, past events and looking to the future – that influenced the issues that participants reflected on when giving their answers. However, the analysis also produced a theme that went beyond the initial template as respondents took the liberty of providing insights into their lives that did not always fit the questions posed. The third theme, hierarchy of life issues, was further aided by using a gendered approach to reading the data. The findings did not differ between the care homes, with themes developed from answers given by participants in both care homes. Only the sub-theme ‘Care home staff's time and ability to turn a blind eye’ was developed solely on responses from care home B. The responses by the three participants living in independent units in care home A did not differ in the length of answers provided nor did they include themes that were not mentioned by the other participants.
Findings
Three themes emerged from the analysis. The first theme, care home setting, illustrates how daily life was reconfigured through the social isolation of residents in the socio-physical environment of the care home during the initial contact ban and during the first phase of relaxations. In addition, the importance of staff engaging with residents is presented. The second theme, biographical sense of resilience, illustrates how life-changing events from as far back as child and young adult life phases, but also later, shaped residents’ understanding of who they were and how they coped with the current societal and personal crisis brought about by the pandemic. The final theme, hierarchy of life issues, brings into focus that as much as the pandemic and the accompanying social reactions pose major hurdles to living the life residents hoped for, they have present life issues that are more immediately important.
Care home setting
The way residents replied to questions around the impact of SARS-CoV-2 on their lives was shaped by the physical and social environment of the care home in which they lived. In care home A, three participants lived in independent living units which allowed them to maintain a level of independence despite increasing frailty. Other participants from care homes A and B made reference to arrangements that had structured their day prior to the restrictions brought about by the pandemic, such as visiting other residents, being able to choose from a large programme of daily group events, going for walks in the garden or going to local shops. One wheelchair user talked about being able to get to work (sheltered workshop), another of moving freely around the care home to visit neighbours and chat to staff. Dropping in on neighbours, chatting in the communal areas or organising small group get-togethers all came to an abrupt halt in mid-March with care home managers, staff and residents not knowing how long these restrictions would have to stay in place. At the point of the interview, residents had just experienced the first phase of relaxation of isolation rules. They describe how they dealt with the lockdown and what they were doing currently.
Daily activities
Without the possibility of seeing outside visitors, leaving the building and moving within the building, residents explained that their activities were reduced to those they could do in their room: watching videos and television, doing crosswords, listening to music and talking on the phone. Phone calls were described as important as they had to replace the social contacts they usually had. None of the residents talked about using computers or social media as neither of the care homes have internet access for residents, which reflects the current situation of limited digital supply in most care homes in Germany (Endter et al., Reference Endter, Hagen and Berner2020).
With the relaxations brought about in early May 2020, residents talked about daily routines that were much the same as during lockdown but with more possibilities of seeing other residents and having a close relative or friend visit once a week:
I spent a lot of time in my room. Now I can ask to be pushed to the communal area on my floor. To begin with we were not to have much contact and stay alone. I watch television, do the crosswords. Once a week my niece comes to visit. (Interviewee 11, 98-year-old woman, by proxy)
However, the restricted nature of the visits (not in their room, with a mask and social distancing rules) had a severe impact for many of the respondents, especially those who were used to being visited every day. In addition, residents who were hard of hearing or had visual impairments found communication severely curtailed. Being only able to see visitors in the communal area meant that bed-bound residents were taken there in a wheelchair, which was too exhausting for some:
Before Corona my family visited every day, now only once a week. But it is too exhausting for me downstairs in the communal area. (Interviewee 14, 98-year-old woman, by proxy)
At the other end of the spectrum, two men mentioned enjoying the freedom of going for walks and frequenting local shops, while others were pleased that staff could shop on their behalf.
Except for a reinstated small gymnastic group in home B, group activities were still not available and missed by many not only for their social dimensions but also for providing a daily structure, exercising decision-making and as something to look forward to. A 76-year-old man explained: ‘The group sessions always meant that you had contact with other residents’ (Interviewee 18, by proxy). This in turn had an effect on residents’ emotional states, with responses including comments on mood swings, boredom, lethargy, hopelessness, anger, feelings of uncertainty and exclusion. In a pragmatic approach to dealing with the restrictions, one 91-year-old woman explained that she had ‘more time to dwell on the past as there was so little happening in the present’ (Interviewee 3, by proxy). An 83-year-old woman was more acrimonious and explained that ‘Corona is time taken off life expectancy’ (Interviewee 5, by proxy).
Care home staff's time and ability to turn a blind eye
Eight of the 14 interview participants from care home B explicitly mentioned care home staff coming around to their rooms for a daily chat, possibly reflecting that staff members in this project had been trained to be particularly sensitive to the emotional needs of the residents. This appears to be an active step on behalf of the care home to make up for the social spaces usually available to residents. Another group of participants from the same home described more illicit activities, such as visiting other residents or joining the ‘news club’:
I go to the news club every morning. Officially that is not allowed because of Corona, but a few of us just meet up. (Interviewee 10, 88-year-old woman, by proxy)
The ‘news club’ had been an official group available in care home B prior to the pandemic, suspended during contact ban, and not reintroduced at the time the data were collected. However, three respondents described meeting up to discuss current events in the room of one resident every morning. As these insights came from respondents who had their answers written down by a member of staff, it may be assumed that these activities were of an informal nature, officially not allowed, but tolerated by staff who turned a blind eye.
Biographical sense of resilience
The second part of the interview asked participants about events in their lives that might have helped them in coping with the changed social reality brought about by the pandemic or that had parallels with the current situation. The responses can be divided into learning experiences, such as becoming a disciplined or patient person, and surviving the perils of the Second World War. Despite the overlap of the two, responses belonging to the former highlighted the capacity of learning from difficult times, knowing that there is no certainty and that things will always change whether for the better or worse. One man, aged 91, wrote: ‘patience from being married → to bear things together’ (Interviewee 6, by proxy); others mentioned bereavement or ill-health and overcoming sorrow or regaining health.
Responses to the latter and referring to the Second World War drew on the chaos and uncertainty of the wartime and post-war period, including experiences as prisoner of war, hunger and fleeing home. These events were presented as a life phase with little choice and doing as one was told. In the words of an 80-year-old man: ‘The post-war period taught me how to adapt to circumstances – now it's Corona’ (Interviewee 16, by proxy). Participants were united in their view that the COVID-19 pandemic could not be compared to their experiences of the Second World War both in quantity or quality. At the same time, they acknowledge that these life events help them cope with the new social and environmental reality brought about by the pandemic: ‘The war, the dreadful experiences during that time made you robust. Corona is nothing in comparison’ (Interviewee 4, 95-year-old woman, by proxy). Several respondents felt that the virus was not a particular threat to them as they were safe in the care home.
Across the responses to questions about the past, there was an overarching feeling that, like all previous events, the pandemic will pass as well. More generally, and in line with promoting factors of resilience, several participants mentioned traits such as being a patient person, taking things calmly, not minding being on their own and thus not feeling lonely. A 92-year-old man mentioned managing his mental state by thinking of something positive from their past: ‘thinking of singing in my choir’ (Interviewee 21, by proxy); the oldest woman among the participants drew on her religious belief and ‘god's mercy in difficult times’ (Interviewee 22, by proxy).
Hierarchy of life issues
Twelve residents’ responses highlighted challenges (work, health, partners) in their lives that were more pressing to them than dealing with the pandemic. Another set of three responses shifted the focus away from their private situation to hopes and challenges for society at large. Both point to a hierarchy of life events and issues in the lives of the residents that became visible in the analysis through the gender perspective.
Personal challenges
The youngest respondent (61 years of age) was a woman with learning disabilities who had been going to work in a sheltered workshop on a daily basis prior to the contact ban. At the time of the interview she had not been able to return yet. All her responses to the questions related to wanting to go back, which shows how important the ability to work was to her. Connected to this lacuna in her current life were worries about not earning money. She described herself as being locked in her room, only having contact with the outside world through her balcony and ‘feeling as if a leper’ (Interviewee 2, by proxy). Her case is salient, as increasing numbers of people with learning disabilities are growing old and moving into residential care settings. Germany, unlike many other countries, has been slow in deinstitutionalising the care of people with learning disabilities, so that transitions into residential care settings are not uncommon where residential settings and sheltered living arrangements are no longer suitable or family support is no longer available, e.g. due the death of parents (e.g. Frewer-Graumann and Schäper, Reference Frewer-Graumann and Schäper2015). Although her status as an employee was very different to those of the other residents, her desire to go out to work was mirrored by an 83-year-old woman who wished to return to the voluntary work in which she had been involved: ‘I miss my work with older people’ (Interviewee 8, self-completion).
Maybe unsurprisingly for persons who live in a care home and who have experienced fast or slow deterioration of their health and physical capabilities, concerns around health emerged as a central theme from responses. A reoccurring wish voiced by respondents when asked about the future was that their health status should stay the same or not get worse: ‘I worry about my personal health the most. Maybe it is selfish, but I worry that my Parkinson's could get worse’ (Interviewee 19, 79-year-old man, by proxy). There was also a fear of becoming ill (though not of contracting COVID-19) and as a result being more dependent on care and less mobile. Two respondents had only lived in care home B for four weeks at the time of being interviewed. Both were still coming to terms with having to leave their home due to a fall and fracturing bones. One of them was hoping that her cat could join her in the care home, whereas the other was determined to become mobile again so that she could move back home.
For two other residents, concerns for their spouses affected them more than life during the pandemic. An 80-year-old man worried about his wife's dementia and a 74-year-old woman worried about the behaviour of her husband who was still living independently. She provided a long answer to the question about her present situation whereas she gave short and unspecific answers to questions on past events and the future. Her response to the first question is indeed the longest among the participants:
My husband used to come to my room every day and would stay all day. I didn't like that, but he doesn't know what to do with himself. Now he can come once a week by appointment for 30 minutes. He doesn't want that. Now he sits in front of the main entrance all day and wants me to spend time with him there. I get in trouble because of that. I understand [the rules] but my husband doesn't. I smoke outside. All of this gets on my nerves, makes me nervous. I don't know what to do.
In response to the question what personal traits the pandemic had increased, she adds:
I am not good at defending myself against my husband. It is worse now as I have a bad conscience. (Interviewee 20, by proxy)
Her hope was that her husband could move into her care home, as he was not good at looking after himself.
Challenges and hopes for society at large
Many participants made comments on political and social developments. However, they remained at a general level of, for example, concerns for the economy, rising unemployment or rising SARS-CoV-2 infection rates. In addition, these comments moved on a spectrum of disappointment that people rarely change their ways to being heartened by the support shown by younger generations towards older people. Three residents actively deflected from their own personal future and expressed their hopes and concerns for society at large beyond the challenges posed by the pandemic. The oldest participant, a 100-year-old woman explained: ‘the hatred in the world is the only thing that moves me, the terror and the destruction’,and later on: ‘to be there for one another and support each other, that is what I hope for’ (Interviewee 22, by proxy). The hope for social change, particularly in view of following generations, was echoed by an 87-year-old woman who wanted the children of the Fridays for Future movement to become ‘strong and radical’ (Interviewee 1, self-completion). A 91-year-old woman talked about not having a future anymore and expressed the wish that children should not suffer from lockdown and social distancing rules.
Discussion
The research project had set out with questions as to how residents in care homes experienced the contact ban and the first phase of relaxations. In addition, it wanted to know what social/institutional and intra-personal resources were available to residents during that time, how they managed their day and what their outlook for the future was. To achieve this the team drew on the concepts of agency and belonging, resilience, as well as a gendered perspective on ageing. In the following, the findings are discussed in light of the inter-disciplinary conceptual perspectives or ‘lenses’ introduced earlier.
The activities the residents reported held few surprises but underpinned the need to provide an environmental lens for interpretation. Moreover, they described days structured by mealtimes, television programmes and naps which, too, are known to provide reliable time-frames and environmental segments in institutional settings (Artner, Reference Artner2018). Recent years have seen a shift away from daily structures merely aimed at fulfilling bodily functions (e.g. food, sleep, medication) to encouraging residents’ participation in activities that are meaningful to them rather than just filling time (Schulz-Nieswandt, Reference Schulz-Nieswandt2020). These changes chime with shifting images of ageing in which later life is not viewed as a residual category and older people (whether living independently or in a care home setting) are not depleted of agency. The multiple meanings attached to the programme of daily and weekly activities usually available to the residents interviewed underscores the importance of these participatory approaches. Agentic decision-making was not only evident in the uptake of activities such as the ‘news club’ and going to the shops, but also in mourning the lack of choice and capacity to choose from activities since the start of the pandemic. This emphasises the role of socio-environmental areas for specific functions but also long-term patterns of habits that reflect processes of emotional bonding and belonging to the care home environment. The findings on how residents filled their days, what they wished for (e.g. cat) and how they applied hierarchies of importance to emotional experiences and life events, suggest that they were able to enact agency and belonging in place (the care home) despite some of their physical and mental limitations. However, further work is needed to increase agency and meaningful activities through access to modern digital infrastructure (Bundesministerium für Familie, Frauen, Senioren und Jugend, 2020). From an environmental, as well as from a resilience perspective, the provision of such basic requirements can serve to reduce social isolation and to foster resilience in care homes (Bundesministerium für Familie, Frauen, Senioren und Jugend, 2020).
The insights residents gave on their emotional states ties in with research on the mental and physical effects of prolonged social isolation on older people and, in particular, on residents of care homes (Spitzer, Reference Spitzer2018). At the same time, interviewees were clear about being well suited to deal with challenges brought about by the pandemic, because they considered the care home to be safe and because they had learnt to endure/survive externally imposed pressures across their biographies. For some residents, these were connected to wartime experiences; for others, these were surviving illness and bereavement and having learnt a sense of patience and perspective across their lives. Insa Fooken (Reference Fooken and Maercker2009) talks about the possibility of growth for people who have come through traumatic events. In this understanding of resilience, reminiscence and reflection enable individuals to express what they experienced with significant others. The idea here is not just about coming through or making up, but to reach a stage of personal growth that exceeds that of coping. The findings show that several residents were able to reflect on the social realities of the pandemic for society at large in relation to personal experiences but also in light of their shrinking personal future. This inkling of growth among some of the oldest participants resonates with what Harry Moody has called ‘legacy and environmental advocacy’ (Moody, Reference Moody2009/10). Here he develops an ideal type of ‘eco elders’ who are memory keepers (providing a collective memory of past events), exercise generativity (parting knowledge to following generations), act wisely and engage in lifelong learning at the same time as enjoying freedom from social obligations. For Moody, this ideal type cannot be lived by individual people but requires communities and generations to work together. Thus, the voices of the residents are not only examples of memory keeping and generativity, but they reach out (through the research project) to those outside the care home.
Findings relating to a hierarchy of life events point to the importance of a gendered lens on understanding residents’ lives during the pandemic. Themes such as the worries over being allowed to return back to work, a wife's dementia or a husband's troubling behaviour would have been overlooked in an analysis not sensitive to intersections of age, gender and ability (Calasanti and Slevin, Reference Calasanti and Slevin2001). Combinations of social inequalities are associated with differential power/resources, life chances and lived experiences. Thus, they are central to understanding later life and how people's lifecourses remain prevalent both in terms of experiences and situatedness within hierarchies of power as they age (Holman and Walker, Reference Holman and Walker2021). The three examples given are striking as they render visible issues not always considered relevant to care homes: wanting to work, a husband caring for a wife and power issues within a marriage. They are proof of how care homes are changing as residents’ chronological age spectrum can span four decades; male residents are increasing in number (one-third of participants were men) and more residents have husbands, wives or partners to worry about either within the care home or outside it. Two women express a desire for agency so as to change their current situation. But in one case the resident is hindered by the pandemic to go to work, and in the other the pandemic brings to the fore a situation that has been ongoing (husband). Both feel powerless as their experiences are set against the current health regulations (reduced contact with the outside world) and socially constructed and engrained images of what is means to be a full member of society (being economically productive up to the age of retirement) or a wife (by caring for a husband). When considering and working towards residents’ health and wellbeing during and after the pandemic, it is important to keep a focus on how their lives are shaped by age, gender and other social inequalities (Sutherland et al., Reference Sutherland, Ward-Griffin, McWilliam and Stajduhar2016).
Limitations and strengths
The research has three limitations, of which the challenges posed to collecting data by proxy have been considered in detail in the Methods section. The second limitation is that participants’ responses were not audio-recorded, a point that should be considered in future research studies. Thirdly, the findings that are based on the responses of 22 residents of two care homes in Frankfurt am Main are not representative of care homes in Frankfurt am Main or beyond. However, the breadth of topics provided in the open-ended interview question and the rigorous deductive and inductive analysis of the data have provided insights into residents’ perceptions, attitudes and experiences during the early phase of the pandemic. By reflecting the findings with the conceptual approaches of the research, they provide an understanding that can be transferred to similar settings. In terms of strengths, this is one of few research studies exploring the experiences of older people in care homes during the COVID-19 pandemic.
Conclusion
The findings highlight the importance of rapid response at the local level of the care home that enables as much social contact as possible at the same time as ensuring residents’ safety. This balance of responding to the restrictions imposed by local health authorities and upholding the principles of participation and personal freedom pose significant challenges to care home managers. However, this negotiation of external requirements, providing a safe, functional and meaningful environment for staff and residents, and meeting residents’ multiple needs, that go far beyond those posed by the pandemic, is one that is open-ended. In this circular process of reviewing the implementation and impact of ever-changing policy and heath regulations in the shifting sands of the care home, the central focus should remain on the needs of the residents and staff (in terms of vulnerability and capacity for resilience). In this ‘ethic of mindfulness’ (Conradi and Vosman, Reference Conradi and Vosman2016), a balance is struck between people requiring support to live well and those providing care to be attentive to the need of self-care in this caring relationship (Schulz-Nieswandt, Reference Schulz-Nieswandt2020). To this extent, further research is needed on the experiences and views of care staff and managers caught in the middle of regulations and ethical values of delivering care during the ongoing pandemic.
Acknowledgements
The authors would like to thank several people: the care home managers for allowing this research to take place; the depression case managers for showing such enthusiasm in collecting data; and the residents who provided us with rare and personal insights into their lives.
