The impact of the COVID-19 restrictions on nursing home residents: An occupational perspective

ABSTRACT

Background: In Ireland, stringent restrictions were implemented to protect nursing home residents from contracting COVID-19. There is limited empirical research on how restrictions impacted residents’ occupational engagement or well-being. This study explored the impact of COVID-19 restrictions on the occupational engagement of nursing home residents and considered implications for occupational science.

Methods: Using qualitative descriptive design, semi-structured telephone interviews were conducted with five residents in one nursing home. Two online focus groups were conducted with seven nursing home staff working across five sites. Data were analysed using interpretive thematic analysis.

Results: Three overarching themes emerged regarding residents’ occupational engagement. ‘Loss of valued occupation’ related to residents’ reduced engagement in social and leisure occupations, with an erosion of the quality and meaning of their routine daily activities. ‘Counting the costs of restrictions on residents’ well-being’ revealed profound impacts on residents’ physical and mental health, including reduced mobility, weight loss, reduced independence, low mood and increased fear, anxiety, and frustration. ‘Finding resilience in the face of adversity’ indicated some hopeful adaptive and coping strategies among residents.

Conclusions and implications: This study brings an occupational perspective to the impact of COVID-19 on nursing home residents by highlighting issues beyond infection control and virus transmission. Findings contribute to occupational science knowledge by highlighting issues of occupational deprivation, occupational disruption and reduced occupational choice, and ripple effects on well-being. Nursing home residents’ perspectives must be prioritised in future research and policy decision-making in responding and adapting to pandemics.

背景：爱尔兰实施了严格的限制措施，以保护养老院居民免于感染 COVID-19。关于限制如何影响居民的生活活动参与或幸福感的实证研究有限。本研究探讨了 COVID-19 限制对养老院居民生活活动参与的影响，并思考对生活活动科学的影响。

方法：采用定性描述设计，对一个疗养院的五名居民进行半结构化电话访谈。与在五个站点工作的七名疗养院工作人员进行了两个在线焦点小组访谈。使用解释性主题分析对数据进行分析。

结果：关于居民的生活活动参与，出现了三个总体主题。 “失去有价值的活动”与居民对社交和休闲活动的参与减少有关，削弱了他们日常活动的质量和意义。 “计算限制居民福祉的成本”揭示了对居民身心健康的深远影响，包括行动不便、体重减轻、独立性降低、情绪低落以及恐惧、焦虑和沮丧增加。“面对逆境寻找韧性”表明了居民的一些适应和应对策略。

结论和启示：本研究通过强调感染控制和病毒传播以外的问题，从生活活动角度探讨 COVID-19 对养老院居民的影响。研究结果通过强调生活活动剥夺、生活活动中断和生活活动选择减少以及对幸福感的连锁反应等问题，为生活活动科学知识做出了贡献。在未来的应对和适应流行病的决策研究中必须优先从养老院居民的角度来考虑。

Antecedentes: En Irlanda se aplicaron estrictas restricciones orientadas a proteger a los residentes de hogares de ancianos ante la posibilidad de contraer la COVID-19. La investigación empírica sobre las consecuencias de dichas restricciones en la participación ocupacional o el bienestar de los residentes ancianos es escasa. Este estudio examinó el efecto de las restricciones resultantes de la pandemia en la participación ocupacional de los residentes en hogares de ancianos, al tiempo que evaluó las implicaciones para la ciencia ocupacional. Métodos: se realizaron entrevistas telefónicas semiestructuradas con cinco residentes de un hogar de ancianos, utilizando un diseño descriptivo cualitativo. Además, se llevaron a cabo dos grupos de discusión en línea con siete empleados de dichos hogares que trabajaban en cinco centros. La información resultante se sometió al análisis temático interpretativo. Resultados: Se identificaron tres temas generales relacionados con la participación ocupacional de los residentes. La “pérdida de ocupación valiosa” hace referencia a la menor participación de los residentes en ocupaciones sociales y de ocio, con la consiguiente erosión de la calidad y el significado de sus actividades diarias rutinarias. El “recuento de los costos de las restricciones en el bienestar de los residentes” puso al descubierto profundos impactos en la salud física y mental de los mismos, por ejemplo, reducción de la movilidad, pérdida de peso, disminución de la independencia, bajo estado de ánimo y aumento del temor, la ansiedad y la frustración. “Encontrar la resiliencia frente a la adversidad” caracterizó algunas estrategias de adaptación y afrontamiento esperanzadoras entre los residentes. Conclusiones e implicaciones: este estudio aporta una perspectiva ocupacional al estudio del efecto de la COVID-19 en los residentes de hogares de ancianos, poniendo de manifiesto cuestiones que van más allá del control de la infección y la transmisión del virus. Los hallazgos contribuyen al conjunto de conocimientos de la ciencia ocupacional, pues destacan las cuestiones de privación ocupacional, interrupción de la actividad laboral y reducción de la elección ocupacional, así como los efectos secundarios sobre el bienestar. En el futuro, se debe dar un lugar prioritario a los puntos de vista de los residentes de los hogares de ancianos en la investigación y la toma de decisiones sobre políticas públicas orientadas a responder e impulsar adaptaciones ante las pandemias.

KEYWORDS:

• Occupational science
• COVID-19
• Occupational engagement
• Nursing home
• Occupational deprivation
• Well-being

Following the World Health Organization’s declaration on the 11^th of March 2020 of COVID-19 as a global pandemic (WHO, 2020), attention quickly shifted to congregated settings, amid concerns about disease transmission, risk of mortality, and reduced resources (Fallon et al., 2020; Gurwitz, 2020; Weech-Maldonado et al., 2021). Nursing homes, which are residential facilities staffed by healthcare professionals that provide long-term care to older adults and those with disabilities or illnesses (Sanford et al., 2015), are one such setting. The increased mortality rates in nursing homes internationally (Thompson et al., 2020) highlighted how COVID-19 disproportionately affected nursing home residents (Fallon et al., 2020). Concern for this vulnerable population during a pandemic inevitably led to the imposition of control measures and restrictions. From 6^th March 2020, restrictions designed to curb transmission were imposed across private and voluntary nursing homes in Ireland (Pierce, 2020). International guidance (WHO, 2020) and national guidance (Health Service Executive, 2022) recommended limiting visitors, implementing social distancing, restricting group activities within the nursing home, curtailing resident movement throughout the home, using personal protective equipment (PPE), and isolating residents who had been infected with COVID-19 (D’Adamo et al., 2020; Dosa et al., 2020; McMichael et al., 2020).

To date, research on COVID-19 in nursing homes has focused on infection control and disease transmission, rather than the wider impact on the lives of nursing home residents. Occupational engagement, which relates to what people do, where, and with whom they spend their time (Nilsson et al., 2013; Reid, 2008), has been largely overlooked, yet nursing home residents are occupational beings and meaningful occupational engagement can contribute to their independence and self-efficacy (Richards et al., 2015). This study explored the connection between occupation, environment, health, and well-being in nursing home residents during the COVID-19 pandemic in Ireland. From an occupational science perspective, there was a particular focus on exploring the implications of COVID-19 restrictions for residents on issues related to occupational engagement.

Occupational Engagement in Nursing Homes

Whilst the literature extolling the virtues of occupational engagement in nursing home settings is compelling, evidence also suggests that, in reality, opportunities for occupational engagement can be quite limited. Numerous studies acknowledge the value of occupational engagement in nursing homes, as it improves the psychosocial well-being and dignity of residents (Buedo-Guirado et al., 2020; Slettebø et al., 2017) and positively influences their identity and integrity (Mondaca et al., 2018). However, the literature also recognises that nursing home residents often experience a lack of occupational choice (Causey-Upton, 2015), as some nursing homes are not able to tailor activity programmes to individual residents or promote their engagement in their chosen valued occupation, disregarding their views and preferences (Björk et al., 2018; Slettebø et al., 2017). Furthermore, many nursing home residents experience occupational alienation, in that options about what to do are limited and residents often spend their time passively in their rooms with minimal opportunities for occupational engagement or stimulation (du Toit et al., 2019; Hansen, 2013; Mondaca et al., 2018). Whilst engagement in meaningful occupations in nursing homes is possible, it must be actively promoted, and tailored for the individual’s values and interests (Mondaca et al., 2018). It also frequently requires facilitation by staff members, however, understaffing and workload demands often prevent well-intentioned staff from assisting residents with meaningful occupational engagement (Gustavsson et al., 2015). Taken together, these studies suggest that, prior to the COVID-19 pandemic, nursing home residents already had reduced opportunities for occupational engagement. The COVID-19 restrictions were likely to have further reduced nursing home residents’ opportunities to engage in occupation.

Among the key barriers to active ageing in nursing homes are deterioration in physical and mental well-being, reduced social contact, and decreased levels of functioning (Fernández-Mayoralas et al., 2015). COVID-19 restrictions may compound these barriers, impacting negatively on nursing home residents’ engagement in active leisure occupations (Ammar et al., 2020; Aubertin-Leheudre & Rolland, 2020). Research shows that older adults, who were relatively active prior to the outbreak of COVID-19, are now leading more sedentary lifestyles as they comply with COVID-19 restrictions (Brooke & Jackson, 2020; Hartmann-Boyce et al., 2020). Older adults who are more mobile tend to retain independence in their daily occupations (Lee et al., 2020). While adults naturally become more frail and less mobile as they age, the rate of this decline increases with excess sedentariness (Blodgett et al., 2015; Del Pozo-Cruz et al., 2017; Gennuso et al., 2016; Lee et al., 2020; McPhee et al., 2016). Thus, increased sedentary time as a result of the COVID-19 restrictions is likely to cause older adults and nursing home residents to become more frail and less mobile over time. The need for older adults to engage in physical activity, avoid sedentary behaviour, and minimise the risk of increased frailty during COVID-19 has been acknowledged (Aubertin-Leheudre & Rolland, 2020; Goethals et al., 2020), however few studies have explored this in a nursing home context, and no studies have done so in Ireland.

Loneliness and Social Isolation

Loneliness and social isolation are defined respectively as a subjective feeling of social isolation (Holt-Lunstad et al., 2015) and an objective lack of social connections (Coyle & Dugan, 2012). Social relationships fulfil an important role in combatting loneliness and isolation, particularly among nursing home residents. Social relationships include those with other residents, staff, and residents’ families (Stadnyk et al., 2017), which all help to combat the risk of loneliness and isolation among nursing home residents. These relationships have been identified as an important predictor of nursing home residents’ quality of life (Custers et al., 2012), life meaning, and satisfaction (Haugan, 2014), given that loneliness impacts negatively on residents’ overall health and well-being (Drageset et al., 2012; Nyqvist et al., 2013). Yet the risk of both loneliness and social isolation in nursing homes is high (Cacioppo & Cacioppo, 2018; Parmenter et al., 2012), as the intensity and frequency of social interactions within nursing homes often does not meet the needs of residents (van Dijck-Heinen et al., 2014). Evidence suggests the value in promoting social contacts for residents (Parmenter et al., 2012) and implementing various interventions to reduce social isolation, such as social facilitation, ‘befriending’ and animal visiting interventions (Gardiner et al., 2018).

Emerging evidence on the impact of COVID-19 recognises the potential for older people to become increasingly isolated during the pandemic and their need for support to minimise this risk (Brooke & Jackson, 2020). Technology can be used as a communication tool for overcoming social isolation (Baecker et al., 2014; Chen & Schulz, 2016; Khosravi et al., 2016), and efforts are being made in nursing homes to mitigate the absence of visitors through the use of alternative communication methods, including video calls on tablets or computers. However, this may be inappropriate for residents with dementia, who benefit from physical contact or hearing the nearby voice of a relative as a source of comfort (Trabucchi & de Leo, 2020). Padala et al. (2020) found that video calling family members with dementia during COVID-19 reduced agitation and anxiety in residents, although the small sample size means the findings should be interpreted with caution and there is a need for replication with larger samples. A larger study of participants living in the community also concluded that technology was a useful tool in maintaining social connectedness during COVID-19 (Goodman-Casanova et al., 2020), indicating the utility of technology in helping to overcome some of the loneliness and social isolation challenges faced by nursing home residents. However, much of the research on social isolation and loneliness excludes nursing home residents with a cognitive impairment, thus the issues these residents face could differ from those of other adults (Drageset et al., 2012; Jansson et al., 2017; Puvill et al., 2016). Moreover, most of the research on nursing home residents is presented from the staff or caregivers’ perspective, neglecting the views of the residents themselves.

In summary, the literature in relation to COVID-19 in nursing homes is limited. There is scant empirical research on the implications of the public health guidance/restrictions for nursing home residents’ occupational engagement or well-being. This study sought to address this gap by exploring the research question “How have the COVID-19 restrictions impacted on the occupational engagement of nursing home residents?”. Findings can make an important contribution to occupational science knowledge by exploring issues of occupational disruption, occupational deprivation, and reduced occupational choice, as well as the wider implications for residents’ well-being.

Methodological Approach and Methods

This study adopted a qualitative design, using a qualitative descriptive approach to explore the phenomenon from the perspective of those experiencing it (Bradshaw et al., 2017) and provide a comprehensive description of experiences, in language that is easily understood (Sandelowski, 2000). This approach can provide the perspective of service users and healthcare staff, exploring important issues relevant to a practice area (Doyle et al., 2020; Neergaard et al., 2009). Qualitative description is also recommended as a relevant approach where the aim of the research is to get first-hand knowledge of patients,’ relatives’, or professionals’ experiences (Neergard et al., 2009). Such studies have the potential to translate directly to health care situations and provide clear information on ways to improve care provision (Sullivan-Bolyai et al., 2005).

Participants and recruitment

Strict COVID-19 protocols in Ireland at the time of research conduct made recruitment a challenge. However, access to the nursing home residents was facilitated by the fact that the second author was a former employee of the nursing home. The Activity Coordinator in the nursing home acted as the facilitator in recruiting participants. The criteria for inclusion are shown in Table 1.

Table 1. Criteria for inclusion of study participants

Inclusion criteria: Residents	Inclusion criteria: Staff
Resident in a nursing home Older adult (65+) Able to communicate verbally or with assistive technology Capacity to consent and participate in an interview	Staff member in a nursing home before and during COVID-19 pandemic Staff member working closely/directly with residents (i.e., nurse, carer/healthcare assistant, activity coordinator)

Purposive sampling was used to acquire the sample. The facilitator distributed an introduction letter and information letter to nursing home residents, based on the inclusion criteria. Those who were interested in taking part contacted the researchers directly or via a member of staff. Written and verbal consent was obtained prior to their participation on the study. Demographic information regarding each participant’s background was gathered. Two male and three female residents were recruited for the interviews (Table 2). Due to COVID-19 restrictions, in-depth semi-structured interviews were conducted with nursing home residents via telephone call (Adams, 2010).

Table 2. Demographic information of nursing home resident participants

Resident (pseudonym)	Age (years)	Gender	Years in nursing home
James	68	Male	10
Joe	74	Male	7
Mary	83	Female	2
Maura	97	Female	6
Nora	74	Female	1

Through convenience sampling, seven staff members (all female) from five different nursing homes were recruited for focus groups (Table 3). Due to overwhelming work demands in the nursing home where the interview participants resided, only two staff participants were available to take part in a focus group. The other five staff members were recruited through facilitators known to the first or second authors from four nursing homes in the south-east of Ireland. The facilitator distributed an introduction letter and information letter to staff members, based on the inclusion criteria. Those who were interested in taking part contacted the researchers directly. Written and verbal consent was obtained prior to their participation on the study. Both focus groups were conducted via online video conferencing technology. Having representation from multiple nursing home sites allowed more diverse perspectives and experiences to emerge from the discussions. Notwithstanding the fact that staff members held junior positions and were relatively inexperienced, they were ideally placed to inform the aims of the study as their roles required them to be actively engaged with residents.

Table 3. Demographic information of staff participants

Staff (pseudonym)	Age (years)	Role	Years in role
Chloe	22	Healthcare Assistant	5.5
Clara	22	Healthcare Assistant	4
Ella	21	Healthcare Assistant	2
Hannah	23	Activity Co-ordinator	4
Jane	22	Healthcare Assistant	1.5
Laura	22	Healthcare Assistant	1.5
Rachel	22	Healthcare Assistant	3

Data collection

An interview schedule consisting of questions and probes was developed to encourage residents to elaborate on their occupational experiences in the nursing home. This was piloted with older adults not participating in the study to ensure the questions were suitable. As the purpose of both interviews and focus groups was to address the same research question, the interview schedule for the focus groups with care workers was very similar. The interview schedules for both semi-structured interviews and focus groups are presented in Appendix 1.

Ethical approval was granted by University College Cork’s Social Research Ethics Committee (CT-SREC-2020-19) prior to commencement of data collection. Staff and resident participants completed a questionnaire giving details of their demographic information (age, gender, health conditions, length of time in the nursing home). The first and second authors (GR and RC) collected the data, with one researcher conducting the interviews while the other researcher took field notes. Interviews were audiotaped and transcribed verbatim by the researchers following each interview. Interviews were 15 to 20 minutes in length and took place over a 2-week period in February 2021. Data were collected until comments and patterns began to repeat and no new material was generated, achieving data saturation.

Two separate focus groups, consisting of three and four staff members, were conducted by the first and second author to gain further insights into the topic (Stalmeijer et al., 2014) from those with direct experience in supporting residents’ occupational engagement throughout the pandemic. Small sized focus groups allowed the topic to be explored in-depth and ensured that every participant had an opportunity to share their perceptions, while also being more manageable for the researchers (Morgan, 1996). The discursive style of focus groups enables researchers to gather diverse opinions, allowing participants to challenge, agree, or disagree with one another (Bryman, 2016). Each focus group lasted approximately 60 minutes and took place in February 2021. Written and verbal consent was obtained from residents and staff to record the interviews and focus group discussions.

The aim of the semi-structured interviews with residents was to provoke thinking about the phenomena of interest and uncover residents’ personal, subjective experiences of occupation during COVID-19. The purpose of the focus groups was not to corroborate or refute the findings from the interviews with residents. Rather, by seeking to triangulate two discrete sets of data around a central research question, it was felt that a more complete presentation of findings would be possible. Whilst the interview schedule was conceived on the basis of addressing questions to care workers more as key informants to the central research question, what transpired was a mixture of observations and reflections on residents’ occupational engagement and care workers’ own experiences of ‘caring’ for residents during a pandemic.

Data analysis

Data generated from the individual interviews and focus groups were analysed using reflexive thematic analysis (Braun & Clarke, 2019), an approach that seeks to highlight the researchers’ active role in knowledge production. Interview and focus group transcripts were read and re-read to allow researchers to interpret and gain an overall sense and understanding of the data (Peterson, 2017). The first and second authors then iteratively coded all transcripts using open and comparative coding techniques. The codes evolved throughout the process, facilitating a greater understanding of the meaning of the data (Braun & Clarke, 2019). Emerging themes were grouped into parent-themes and sub-themes to highlight arising concepts and ideas and, as such, represented interpretations of patterns of meaning across the dataset. Following cross-referencing between the first and second author, three parent themes emerged that captured the centrality of the research question. Theme memos and notes, and conceptual maps were used to track evolving relationships between themes.

The themes were then discussed with the third author, with a view to organising codes around a central organising concept and collated into a thematic map (Braun & Clarke, 2021). All three authors then worked collaboratively to select and simplify the data from the transcripts and to identify patterns in the codes, condensing them to form broad categories, also known as data reduction (Braun & Clarke, 2006). They then sought to determine overlapping ideas between the emerging categories and to refine and synthesise these concepts into major themes that captured the essence of the data and represented the initial findings of the study (Braun & Clarke, 2021). Adopting a reflexive and collaborative approach to thematic analysis enabled all three authors to attain rich interpretations of the data through the chosen codes and categories (Braun & Clarke, 2021).

To ensure credibility, we consulted with participants at the end of each interview/focus group to summarise, clarify, and verify the points they discussed. Triangulation increases validity by enhancing the dependability of the data (Moon, 2019). We triangulated data from two different sources (residents and staff members), using two research methods (interviews and focus groups), ensuring that the research was robust and well-developed (Pandey & Patnaik, 2014). An audit trail documented all decisions made throughout the process, including how individual codes became themes. Peer debriefing between authors was conducted regularly and field notes and reflective diaries were used to make explicit the role of the researchers in the research process, formulating a reflexive account of the study (Braun & Clarke, 2019; Carpenter & Suto, 2008).

Findings

Three overarching themes emerged from the data analysis: (a) loss of valued occupation, (b) counting the costs of restrictions on residents’ well-being, and (c) finding resilience in the face of adversity.

Loss of valued occupation

This theme outlines the severe restriction in opportunities for engagement in valued occupation experienced by nursing home residents. Participants highlighted the impact of these restrictions on leisure occupations and on other routine daily occupations, within and beyond the nursing home.

Leisure occupations

Participants described not being able to engage in occupations that were once part of their regular routines, due to restrictions on organised group activities within the nursing home, such as smaller group sizes, online facilitation, or outright suspension or cancellation. Clara (staff member) noted that the cumulative loss of these changes reverberated deeply within the nursing home, reflecting that:

All [has] changed and is just different. They used to have big parties and group activities every day. We used to have exercise classes and people coming in, pet therapy, well-being days, and now they can’t. They’re so used to having their movie days and big groups and it’s just all changed now. It’s just different. (Clara, staff)

Participants agreed that the COVID-19 protocol requiring residents to remain in their bedrooms resulted in reduced opportunity to engage in leisure occupations and disrupted their daily routine. As a result, participants identified reduced opportunities for mobilising to mealtimes and leisure pursuits. For Maura (resident), this imposed sedentary environment directly impacted her capacity to be mobile and physically active: “I am definitely doing less walking now. Only up to the reception, is as far as I can go.” In addition to restrictions within the nursing home, residents reported experiencing a loss in meaningful occupations that they once engaged in outside the home: “I used to go down to the pub. I can’t do that anymore, and that I do miss the few drinks, mixing with the boys, you know” (Joe, resident).

Findings also revealed that the way nursing home residents socialised with family, friends, staff, and other residents had been both reduced and changed due to COVID-19 restrictions, leading to loss of another valued occupation. The absence of face-to-face contact due to the imposition of visitor restrictions resulted in reduced opportunities for social occupations with family and friends. Although nursing home staff attempted to facilitate contact between residents and their families through telephone conversations and video calls, participants unanimously agreed that this form of communication did not compare to the face-to-face contact that was no longer permissible: “I talk to my nieces on the phone, but it’s really not the same” (Maura, resident).

Prior to the restrictions, visitors provided structure and purpose to residents’ day, allowing them to maintain connections with life outside of the nursing home. In the instances where visits were permitted, there were numerous restrictions in relation to time limits, social distancing, and use of PPE. Participants reported finding this challenging, particularly the prohibitions on physically touching or hugging family members and difficulties in recognising visitors wearing PPE. As Hannah (staff member) noted, the cumulative effect of these restrictions had a particularly disorienting and destabilizing influence on residents whose well-being was highly dependent on routine and familiarity.

They are starting to forget their family a bit. They will be like ‘I don’t know that person.’ Husbands and wives, you have to remind them who they are. They are like ‘What are they doing here?’ I suppose the mask doesn’t help because they are like ‘Who is that with the mask?’ (Hannah, staff)

The reduction in opportunities to socialise with visitors mirrors the decreased opportunity for residents to interact with one another. Residents were forbidden from gathering in communal areas, including dining rooms and sitting rooms, instead being confined to their ‘bubbles,’ to curtail the spread of the virus in the event of an outbreak. Not being able to engage informally in communal social spaces was seen as eliminating the chance for residents to form and maintain social connections with other residents: “They had a main sitting room, the atmosphere there was much better, much more homely. They just had way more opportunities to talk to people there” (Laura, staff).

Equally, there was a reduction in opportunities for residents to engage socially with staff. Similar to visitors, residents found it difficult to recognise staff members wearing PPE and reported experiencing barriers to communication, such as lip-reading and reading facial cues. This compounded the sense of disorientation and confusion that residents experienced. “No, I wouldn’t actually recognise the girls. I’m calling them all different names” (Joe, resident). Staff also reported limited opportunities to socialise with residents and highlighted feeling torn between their instinctive desire to engage in meaningful social engagement and chat with residents, versus their obligation not to do so because of COVID-19 constraints. “They love the company as well, that’s all they want. If you could sit with one resident for the whole day, you would. But you have to be mindful of everyone else as well” (Clara, staff).

Routine daily occupations

Participants who required assistance from staff with personal care and routine daily occupations described changes in the ways these occupations were performed, with restrictions on the amount of time staff could spend with each resident making them more rushed and less enjoyable. Staff participants described how these care tasks were now focused on efficiency, rather than on the meaning participants derived from personal care occupations. Therefore, in addition to adjusting to the loss imposed by confinement and reduced opportunities for social engagement, residents were faced with disruption to their normal pattern of occupations and an erosion in the quality of their personal care occupations.

If they are isolating, you have a set time period. You only have your 15, 20 minutes in there. So, you're trying to rush. I think it can be very difficult for them … you obviously want to be able to spend time talking to them and you don’t want them to think that you’re just rushing in to tick off a job done in the morning. (Chloe, staff)

Counting the costs of restrictions on residents’ well-being

This theme describes the consequences of reduced opportunities to engage in occupations on nursing home residents’ physical and mental health. Whilst these are presented as two discrete sub-themes, for more vulnerable residents there appeared to be an inter-connected deterioration in their cognitive status and physical condition following the introduction of COVID-19 restrictions. “We definitely have a few that are more frail. It started with mentally, they were declining a bit, one or two in particular. And then their mobility is gradually declining with it. They’ve just gone so downhill so fast” (Chloe, staff).

Impact on physical health

Staff participants identified a decline in residents’ physical mobility and independence, as they were confined to their rooms and had reduced opportunities for mobilising outside the confines of the nursing home.

They’re not able to mobilize as well and they need a wheelchair to go long distances. Whereas before they would have been able to go out - because we have a big garden out the back, they would have been able to go out themselves. (Chloe, staff)

Staff also described weight loss among residents as an adverse physical effect of the restrictions. This was attributed to residents becoming less motivated to eat their meals as well as to changes in where they ate. As residents were no longer permitted to go to the dining room for meals, the social aspect of mealtimes was lost, with a negative impact on their physical health.

There’s actually also been a huge problem in our place with weight loss. I don’t think there was one resident last month that didn’t lose weight, and there’s 100 residents where I work. (Hannah, staff)

They’re less likely to have a full meal then, because they don’t have the chat, they don’t have the fun aspect of the mealtime. (Chloe, staff)

Additionally, in the absence of communal dining arrangements, residents could no longer make use of environmental cues and prompts to engage in the occupation of dining: “If they saw someone else eating and they saw the food in front of them, they might be more encouraged to eat. If they saw everyone else doing it, they might join in” (Rachel, staff).

Impact on mental health

Whilst residents’ reduced independence in daily occupations and increased frailty could be seen as directly linked to the COVID-19 restrictions, there was also the suggestion that this was underpinned by a more fundamental loss of hope and reduced motivation to maintain independence in relation to more routine occupations. James’ description of being “confined to our rooms” suggests a more fundamental loss of autonomy and freedom of movement. Accounts from staff indicated that, as a result, residents became demotivated and more reliant on them for assistance with these occupations.

They’re not as motivated to keep up their exercises, keep up moving, that kind of thing … ‘What’s the point in keeping mobile when I can’t even go for a walk with my family?’ (Chloe, staff)

They don’t see the point. If someone can wheel me to the toilet, I’m not going to try and go myself. (Clara, staff)

James (resident) reported experiencing feelings of helplessness and depression due to the impact of the restrictions on him personally but also due to a more deep-rooted sense of despair relating to the wider impact on society. “I can do nothing about it; it has been a bad year for me. It’s depressing, you know? I think it is all misery, everything is closed and there is a breakdown in society”. This point was reiterated by staff members, who ascribed visitor restrictions, in particular, as leading to depression, low-mood, and loneliness among nursing home residents. “Residents are so lonely and they’re so depressed. They cry quite often about not being able to see family. They’re just a bit lost” (Hannah, staff). Another factor impacting participants’ mental health was the fear associated with contracting COVID-19 and becoming ill. Residents described feeling anxious about their safety and fearful about the prospect of the virus getting into the nursing home.

I get panic attacks, so I know what it’s like not being able to breathe. It would be frightening. (Joe, resident).

We have one lady who loved going up to the dining room … . But she’s now more anxious and stays in her room every day. She’s even very anxious about coming out and meeting in small groups. She doesn’t know if it’s safe. (Clara, staff)

Both residents and staff emphasised the role the media had played in exacerbating these feelings of fear and apprehension, as they described feeling bombarded with information on the negative effects of COVID-19, particularly in relation to nursing homes: “They get the newspaper and all over the paper is COVID, all over the TV is COVID. There’s all these cases in nursing homes. And it is putting the fear of God into them. The residents are absolutely petrified” (Hannah, staff). Residents also despaired about the future, about when COVID-19 restrictions might cease, or when normal life might resume. One staff participant reported that some residents expressed their overall frustration in the form of misdirected aggression and aggravation towards staff:

Will they ever get rid of it, like? Is this going to be always there? No one has the answers. (Joe, resident)

We have one or two [residents] that get really frustrated in themselves. They are snapping at staff when it would be very out of character for them to be like that. (Chloe, staff)

Participants also highlighted the unique challenges residents with dementia were experiencing due to COVID-19 restrictions, particularly in relation to the loss of physical contact with visitors as a result of the social distancing measures. PPE was identified as a source of particular confusion among these residents and was reported as leading to increased incidence of challenging behaviour. In terms of alternative methods of communicating with family, Nora (resident) expressed how her husband with dementia was struggling to adapt, causing further confusion and distress: “The Skype confuses Liam. He thinks that they are hiding behind the television and all that” (Nora, resident).

Finding resilience in the face of adversity

Despite the loss and disruption, there were examples of resilience and a sense of optimism shown by some residents in the face of restrictions. Notably, residents had developed stronger bonds with staff in the absence of visitors, with staff reporting an increased sense of responsibility for the residents, acting as their advocate in times of need. “I felt more responsible for them because family is such a big advocate for them. If you saw someone going downhill, or you didn’t think they were getting proper support or care, I felt more responsible” (Laura, staff).

Some participants viewed the restrictions in a more positive light and identified feeling safer as a result of the regulations in place in the nursing home and expressed gratitude towards staff for their diligence in protecting the nursing home from the virus: “I’m not worried about the virus no, because I think they have done so well in here and managed to keep it out” (Joe, resident). Two residents in particular took a pragmatic approach and rationalised that the restrictions did not impact upon their occupational engagement as severely as other residents. For Joe, who was already confined in his activities, his routine remained relatively unchanged, as he could still engage in most of his daily occupations without any added restrictions.

“Since I came here 10 years ago, I haven’t gone outside my room. COVID is no difference to me. The other residents can’t leave their room now, but I’m doing it since I came here” (Joe, resident). Nora described how the restrictions were less applicable to her because her husband was also a resident of the nursing home. While she reported missing her family, Nora expressed feeling lucky to have her husband with her: “I have Liam and he has me, so that is a positive for me, that I am here with him” (Nora, resident).

Discussion

The findings of this study address this important gap in the literature and contribute to occupational science knowledge. By demonstrating the link between occupational engagement and health (Kristensen & Peterson, 2015), they demonstrate how participants’ meaningful occupations had the potential to either sustain or undermine their well-being (Yerxa et al., 1990), and the consequences of not participating in occupation (Hocking & Wright St Clair, 2011) in the context of COVID-19. The findings also give an insight into nursing home residents as occupational beings, as they have both the capacity and the need to engage in occupation (Yerxa et al., 1990). This study draws attention to vulnerable and often forgotten people and has the potential to inform the health promotion of this population (Fritz & Cutchin, 2017), during COVID-19 and beyond.

Occupational deprivation in nursing homes is not a new phenomenon (du Toit et al., 2019; Hansen, 2013), however, findings suggest that occupational deprivation among residents has been severely compounded by the COVID-19 restrictions, which have had a profound impact on their leisure occupations. Occupational disruption due to COVID-19 also interfered with residents’ normal patterns of daily occupations, with the significance and meaning of these occupations being disrupted by factors outside of their control (Hammell, 2020b).

COVID-19 restrictions directly impacted residents in terms of restricting movement and depriving them of opportunities for habitual leisure occupations, resulting in reduced stimulation and peer support, and diminished quality in their personal care occupations. Arguably, the impact was even greater in more indirect and existentialist terms. Being confined within their own rooms and deprived of freedom of movement and their normal routines fundamentally changed the atmosphere and essence of residents’ ‘homes.’ The occupational deprivation associated with residents’ social occupations was profound; including a decline in frequency and quality of communications with family and loved ones, the loss of structure and routine, and the loss of social interaction within nursing homes. While nursing home residents were still afforded opportunities to engage in some occupations, these were more functional and focused on efficiency, rather than on meaningful occupations and residents’ priorities. Therefore, occupational engagement in nursing homes changed and was stripped of significance, rendering many occupations less meaningful and more functional.

Lack of occupational choice in nursing homes is not a new phenomenon or solely related to COVID-19 restrictions. Previous research has highlighted how residents have reduced autonomy in their daily time use and are obliged to follow the routine of the nursing home and engage in the occupations available to them (Causey-Upton, 2015). Our findings clearly show that this reduced occupational choice was amplified by COVID-19 restrictions. Those restrictions undermined the already limited opportunities residents had in terms of agency, as they could no longer act independently or have autonomy in relation to the occupations they engaged in, either within or outside of the nursing home. Arguably, for a group with such limited agency and occupational choice prior to COVID-19, these losses are all the more profound.

From the outset of COVID-19, the potential threat to older adults’ physical and mental well-being as a result of restrictions imposed was recognised (Armitage & Nellums, 2020), and our research findings reinforce this. And yet, a public health policy approach that was exclusively focused on ‘protecting’ the most vulnerable and curtailing the spread of the disease, failed to account for the residents’ perspectives, or to consider the potential adverse effects of these restrictions on residents’ health and well-being. The rigid confinement measures and the paternalistic approach to nursing home care led to wide-ranging adverse implications for residents’ (i) physical health, including reduced mobility, weight loss, and frailty; and (ii) mental health, including reduced motivation, low mood, depression, loneliness, anxiety, hopelessness, and frustration. Moreover, the media and the government’s preoccupation with the number of cases and deaths in nursing homes compounded the sense of fear and anxiety that residents felt, with no consideration given to the impact this might have had on residents’ well-being. Overall, there was a lack of consideration given to differing abilities in the nursing home, portraying all nursing home residents as vulnerable, dependent, at-risk members of society, based on their chronological age, thus resulting in negative manifestations of ageism (Ayalon, 2020). The results of this study also challenge the ageist stance taken by policymakers and the media, with participants in this study displaying good insight into COVID-19 and showing signs of resilience and overcoming adversity through identification of positive and adaptive coping strategies in the midst of stark challenges.

Implications

Findings reveal how the occupational engagement of nursing home residents were drastically impacted by the COVID-19 restrictions and had important implications for occupational science knowledge by exploring issues of occupational deprivation, occupational disruption, and reduced occupational choice, as well as the wider implications for residents’ well-being. It is imperative that policy makers and nursing home management in Ireland and internationally recognise the significant impact restrictions have on residents’ physical and mental health and put strategies in place to maintain and improve the occupational well-being of residents. These should include measures to combat occupational deprivation and occupational disruption, to a more holistic approach focused on meaningful occupational engagement, leisure exploration, and lifestyle re-design. The right to equality of occupational opportunities is essentially a human rights issue (Hammell, 2004), indicating the need for a rights-based approach to nursing home care during and after COVID-19.

Due to the heightened occupational deprivation, disruption, and removal of occupational choice during COVID-19, there was a further threat to residents’ engagement in occupation, thus underlining further the need for a comprehensive programme of interventions, focused on the individual occupational needs, abilities, and preferences of residents. Evidence suggests that fostering well-being after a period of occupational disruption requires a focus on engagement in valued occupations and enacting choices in daily routines (Hammell, 2020a). Wider advocacy measures are needed that seek to re-position nursing homes from being seen solely in terms of health, safety, and personal care to a more occupational perspective, encompassing the residents’ views in the process and enabling them to be active decision-makers in how they live their lives. There is also a need for increased advocacy and education to push policy makers and care providers to act on this (Pereira & Whiteford, 2013).

The findings highlight the wide-ranging and insightful perspectives of nursing home residents, which are often overlooked in research. This underlines the need for further research to shed light on nursing home residents’ perspectives on opportunities for occupational engagement, allowing their voices not only to be heard, but to assume a co-design role in research, key policy, and practice decisions in the future.

Limitations

The transferability of these results is subject to limitations. Participants were recruited through convenience sampling. Although the sample size was small, participants were typical of the target populations. Resident interviews were conducted within one nursing home. Staff who participated in focus groups held junior positions, were relatively inexperienced, and did not include any males. This study was limited by the absence of residents with advanced dementia; therefore, findings cannot purport to represent the potentially unique challenges faced by this population group during the pandemic. An additional limitation was the need to conduct interviews remotely through technology. As a result, a person was present in the room for some interviews to facilitate use of technology, for residents who were unable to do this independently. Their presence may have constrained what the resident felt able to say.

Conclusion

The findings contribute to occupational science knowledge by highlighting the reciprocal relationship between meaningful occupation and physical and mental well-being. This study reveals how the COVID-19 restrictions have changed and reduced nursing home residents’ opportunities to engage in meaningful occupations, thus highlighting issues of occupational deprivation, occupational disruption, and reduced occupational choice. COVID-19 restrictions raise issues of occupational injustice for nursing home residents, reducing their already limited occupational choice, and heightening the occupational deprivation they experience within the context of the nursing home. Despite this, participants displayed resilience in overcoming the barriers posed by the COVID-19 restrictions, challenging ageist attitudes in understanding and adapting to this ‘new normal’. Whilst the public health policy focus on preventing and containing the spread of the virus in nursing homes is justifiable, having this as the sole focus is not. Our findings provide a clear call to action to policy makers and nursing home care providers to move beyond this narrow focus and to consider key strategies in response to the ways COVID-19 restrictions impact residents’ overall physical and mental well-being. It is imperative that such strategies are based on the values, interests, and needs of residents and that special consideration is given to nursing home residents with dementia.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Appendix 1:

Nursing Home Resident Interview Schedule

For you, what has changed about life because of the COVID restrictions? (Encourage residents to elaborate, emphasising how it is impacting them).

Daily Routine

• What does your day consist of?

• Talk me through your day from when you get up to when you go to bed

• Are you satisfied with your routine in the nursing home?

• Has your routine changed recently? If so, how?

• How have COVID restrictions changed what you do on a day-to-day basis? How do you feel about these changes?

Occupations

• How often do you take part in activities?

• What kind of activities do you take part in?

• Do you do individual or group activities?

• Why do you like to take part in activities?

• Do you engage in any physical activity? Walking, “chairobics,” etc.

• Has your participation in activities changed recently? How?

• How have COVID restrictions changed your participation in activities?

• How do you feel about these changes?

Socialising

• What do you enjoy about spending time with other residents?

• What do you enjoy about interacting with staff, like (activity co-ordinator) (carer)?

• What do you enjoy about having visitors?

• Can you tell us about how you keep in touch with family/friends outside of the nursing home?

• What do you enjoy about going out for the day from the nursing home?

• Has (X) changed recently? If so, how? How does this change make you feel?

• How have COVID restrictions changed (X) for you?

Daily Living Occupations

• Have mealtimes changed because of COVID restrictions? Where you eat? Why you eat here? How do you feel about eating here?

• Do carers help you with washing/ dressing/toileting? Do you feel like you need more or less help recently?

Staff

• Have you noticed any changes in the way staff are working recently?

• How have these changes impacted you?

• How do these changes make you feel?

COVID Impact of

• Visitor restrictions

• Staff wearing PPE

• Visitors wearing PPE

• Understaffing

• Cocooning in bedrooms

• Overall feelings during lockdown?

• Fear of COVID (fear, anxiety, loneliness, paranoia)

• Illness as a result of COVID

• Positive impacts of restrictions

Staff Focus Group Schedule

1. In what way do you think the COVID restrictions have impacted the residents?

2. Have you noticed any physical changes in the residents because of the restrictions? If yes, why do you think this is?

3. In general, how would you describe the mood of the residents throughout the COVID pandemic? Has this changed from before to now? Why do you think this is?

4. How has the residents routine changed since the restrictions have been brought in (mealtimes, activities, self-care)? How do you think this has impacted them?

5. Socially, has interaction between residents changed because of the restrictions?

6. Have you noticed any changes in the way residents are interacting with staff?

7. Do you think visitor restrictions have impacted residents? If yes, in what way?

8. Do you think staff wearing PPE has had an impact on the residents?

9. Do you think the COVID restrictions have impacted positively on residents in any way?

10. Anything to add/ any questions?