ABSTRACT
This paper comprises two cases illustrating ethical challenges experienced by people working with residents and staff in congregate settings (residential homes) during Covid-19. In congregate settings restrictions were more stringent due to residents’ vulnerability and high risks of the virus spreading. In the first case, a UK social worker recounts his proactive advocacy on behalf of a young woman living in residential care, enabling easing of some restrictions for her. In the second case, a German researcher discusses how limits on entering nursing homes resulted in postponing and then ending a participatory research project, with the researcher regretting loss of contact with a home. Following each case is a commentary from an outsider’s perspective. Both authors foreground their responsibilities to care about people facing difficult circumstances and to take action for change. This suggests that situated approaches to ethics, focussing on particular people, roles and relationships in context (such as the ethics of care and virtue ethics) are helpful in understanding the ethical challenges described. The cases illustrate the extra cognitive and practical effort required to engage in ethical reflection on the implications of new circumstances, in which taken-for-granted ways of being, thinking and acting are difficult or impossible.
Case 1. Challenging blanket rules in residential care: advocating for a young woman in the UK
Anonymous social worker
I am a man working as a therapeutic social worker with looked after children in a UK local authority. One of the primary concerns of people caring for looked after children [during Covid-19 restrictions] has been the removal of ‘structure’ – routines that are important for predictability and consistency. Many looked after children have come from environments with the opposite atmosphere – tension, hostility, high degrees of inconsistency or lack of supervision. This leads to difficulties with emotional regulation, usually responses that are angry in nature. With support, the children and young people can find a strategy to manage this.
I work with a 15-year-old girl, Lisa, who is living in residential care. She has experienced significant domestic violence over a sustained period and has had a number of one-to-one sessions with me to help her manage the impact of this. Lisa has become conscious of the impact that experiencing domestic abuse has had upon her emotions and ability to regulate big feelings. One of Lisa’s strategies in managing anger was to go for a walk outside around the locality of the residential home. Following the first lockdown in the UK, walking has been restricted to once per day. The young people in the residential home were advised that if they left unauthorised, they were likely to be arrested by local police. The policy of the local authority was to ensure that the young people firmly adhered to the ‘stay at home’ advice. Lisa complained that she needed to leave the home for a walk on the odd occasion that she felt anger rising. She cited the fact that staff in the home usually went with her or encouraged her to do so, and was therefore upset that this could not take place.
I agreed with Lisa’s position that she needed to go for a walk outside when she felt herself getting angry and communicated with the team manager about Lisa’s concerns. The manager advised that the restriction on walking outside was the policy of the local authority management. However, he had some sympathy, given that children with disabilities such as ASD [Autism Spectrum Disorder] were exempted from the rule. He requested a written response with my thoughts about challenging this. Following a discussion with my colleagues/peer professionals, I submitted a response, which included the following:
Looked after Children (LAC) have all experienced developmental trauma to some degree and their emotional reaction and responses to any external stressful situation (such as this) are likely at times to be lacking the kind of understanding and reaction we would want. If we consider further that as LAC, they will have attachment difficulties; their own particular attachment strategy will be triggered when feeling stress or a sense that they are not safe in some way. This can be maladaptive, but as the young people are well known to staff, it is generally managed: e.g. needing to go for a walk around to cool off, if feeling angry.
Commentary on Case 1
Sarah Banks
This case exemplifies one of the defining ethical challenges of the Covid-19 pandemic: how do we balance community and public good against individual freedoms and well-being? In crisis and emergency conditions, when there is little time to debate policies and procedures, and risk assessments and predictions are difficult to make, then ‘blanket’ rules applying to all are arguably necessary and justifiable. Population-level well-being and safety are important, and utilitarian arguments based on maximising the greatest good of the greatest number of people are prominent. There is a logic to having clear, general rules applying to all, and there are dangers in allowing exceptions, which may both undermine general compliance and enable individuals to put themselves and others at risk.
However, unlike politicians and policymakers, social workers start with particular people in the context of specific needs and circumstances. It is a social worker’s job to know about and understand the details of the material and emotional lives of the people with whom they work – whether social workers are simply assessing needs or competence on a one-off basis, or have a longer-term relationship, as in this case. During the pandemic, many social workers reported they were unable to do ‘proper’ social work. Indeed, some felt they were acting ‘unethically’, in that blanket policies restricting in-person contact and reductions in services meant that needs were unmet and people’s dignity and rights were infringed (Banks et al. Citation2020). Many social workers felt upset and concerned, but were unable to act. They seemed to experience both ‘moral distress’ (knowing what would be the right response or action in ‘normal’ times, but unable to carry it out in pandemic conditions), and/or a kind of ‘ethical paralysis’ (unable to work out what would be the right course of action in changed circumstances and therefore doing nothing).
By contrast, this social worker took a proactive stance, and was able to fulfil key aspects of his role as a social worker and his responsibilities to Lisa. The social worker does not give a detailed account of the reasoning behind his decision to challenge the application of blanket rules to Lisa’s case. However, he does explicitly point out:
Lisa’s assessment of her need for more walks outside the home, with which he agrees.
The importance of a more flexible and understanding approach by the local authority to the circumstances of particular young people.
The importance of trusting Lisa and other young people to walk outside the home safely.
It is noteworthy that the social worker does not frame his account in terms of Lisa’s rights to make her own decisions and choices, which is a key ethical principle in social work. This makes sense, because in pandemic conditions it is generally recognised that individual decisions about movement and contact affect others, particularly in congregate settings. Rather, his argument is based on Lisa’s particular needs and well-being, and an exhortation to trust her unless or until she demonstrates unsafe behaviour. The written response to the manager of the home refers to the needs and circumstances of young people in local authority care, who generally have experienced trauma related to each person’s life circumstances. The plea the social worker is making is for the local authority to allow for the needs of individual people to be taken into account, and for decisions to be made based on knowledge of those individuals. He makes the point that ‘young people are well-known to staff’. By implication this means staff could, and should, take responsibility for working with each young person on what is their best strategy for coping during the pandemic as safely as possible for themselves and others. This would entail staff themselves also being trusted to use their professional expertise and discretion wisely.
Arguably the ethical frame of reference implicit in this case as it is presented is a relational one, and takes as its starting point the particular relationships and responsibilities between people and the contexts in which they occur. This could be described as a situated approach to ethics, in which what is right is decided in relation to the particularities of each situation (examples of situated approaches include the ethics of care and virtue ethics). This requires much more cognitive and practical effort in making ethical evaluations and acting on them than simply following impersonal generic rules designed to maximise public good (although the latter are important, especially in pandemic conditions). The case is illustrative of the tensions between individual needs and freedoms and the necessity of generic rules manifested not only in social work, but also in all aspects of personal and professional lives and political decision-making during the pandemic.
Case 2. Challenges for participatory action research in nursing homes during Covid-19: a case from Germany
Marilena von Köppen
This case relates to a participatory action research (PAR) project designed to study the potential for improved participation of residents, staff and relatives in the lifeworld of nursing homes in Fulda, Germany. PAR entails people whose lives or experiences are the subject of the study conducting at least some aspects of the research (participatory), with a view to influencing changes in living conditions, practices or policies (action). Nursing homes in Germany are residential facilities that offer nursing care alongside support with daily living from care workers. The majority of residents are older people.
The German Ministry of Education and Research provided funding to Fulda University of Applied Sciences for a four-year research project, starting in 2017. The academic team consisted of two university-based project coordinators and me. While I was the researcher doing the fieldwork on the project, my two supervisors advised and supported me as a reflecting team. The aim was to explore participation possibilities in three nursing homes, researching together with residents, nursing staff, care workers and relatives.
We had already completed the research processes in two homes when we started in a third home in Summer 2019. It was a small, family-style home with only 40 places. The manager and head of staff were very receptive to the project and the residents also accepted us quickly. I regularly joined activities offered to residents and spoke to them in the dining room and other public places in the home. The staff, however, reacted differently. As in the other homes, issues of time pressure and work stress were always present. In particular, the care workers, who are very poorly qualified in Germany, made it clear that they were overworked and dissatisfied. The home management therefore expressed the wish that the project should mainly focus on this issue. However, this created the problem that the care givers did not necessarily participate in the project on their own initiative. Indeed, we were soon faced with major challenges. I noticed that there was no real team feeling between the care workers. There were not even joint team meetings. For me, this meant that it required a very long arduous process to start a joint project with the care workers.
I regularly spent time in the nursing home. Sometimes once a week, sometimes a bit less, to talk to the residents. There were also regular meetings with the manager and head of staff, and later I had one-to-one meetings with care workers. It was very difficult to organise group meetings with the care workers, and we only had three before March 2020. To connect to all the different people living and working in the home, I did an activity that I called ‘coffee break research’ on two occasions. I sat with plenty of coffee and finger food near the elevators. Everybody who came by was invited to have a drink and give their opinion about life in the home. I worked with pictures and noted the stories people told me. Over the day a poster took form. Many people came back several times to watch the poster develop. When the project stopped, the care workers and I had just decided to build up a collection of five-minute activities the care workers could do with residents. It was new that they decided to pool their knowledge and create something collectively. My feeling was that the management really wanted them to participate and would give them leeway. But the care workers were stuck in their everyday struggle to get things done.
It was at this point that Coronavirus struck in March 2020. I was no longer allowed to enter the home, nor were relatives and other visitors. This meant that nursing homes were almost completely sealed off from society. At first it seemed that the lockdown would only last a matter of a few weeks. We interrupted the cooperation but we assumed that we could be active again after the summer holidays in 2020. Then, however, the situation deteriorated as infection rates went up in the region and in Germany as a whole. Since our project funding ended in December 2020, it soon became clear that we would not be able to complete the research process. I asked the home’s management in November 2020 if we could hold a final meeting. However, in addition to a lack of time and overwork on the part of the staff, there was also no facility in the home for, say, a Zoom conference. The only internet-capable computers were in the administrative offices. There was no WLAN, let alone tablets or laptops. In the end, this led to a complete halt of the project. The research team wrote up the findings from the other two homes only, in which there was some improvement in feelings of empowerment on the part of residents and better understandings of roles and views amongst relatives, care workers and volunteers.
I’m still thinking about whether I could have done something differently. My feeling is that I failed as a researcher in this situation. Wouldn’t I have had a duty, especially given the difficult situation in the nursing homes during Coronavirus, to find ways to support them? I realise how participatory action research is different from other research. Since we could not work on our research question under the Coronavirus conditions, from a purely scientific point of view it might even have made sense for us to end the empirical research process and rather move on to writing and publishing, which I did anyway in the months when the Coronavirus restrictions were in place. But as a participatory researcher, I am also an activist. And looking back, I think I should have supported the nursing home. I would have liked to meet the care workers, if not in the home, then outside in order to give them a safe space to talk about their experiences and perhaps to realise that they were not alone and to strengthen their feeling of being a collective group. But would they have been interested in that? I think one problem is that Coronavirus really killed my creativity. With the ‘coffee break research’ I had ‘invented’ a very flexible and useful method that fitted this nursing home in its specific situation. But the overall ambiance of fear and uncertainty did not let me think about something similar for the Coronavirus situation. This leaves me with the general feeling of guilt. My own agency had really diminished.
Commentary on Case 2
Sarah Banks
This case tells us much about the complexities and challenges of participatory action research (PAR), which were compounded by the impact of Covid-19. PAR is usually a slow process, involving building trusting relationships based on mutual respect and shared agendas between people from diverse backgrounds (Abma et al. Citation2019). If academic researchers are involved, usually they pay particular attention to engaging a range of people and sharing some of the power and control over the direction of the research. Clearly this was the path pursued by the author of this case, who took time and care to get to know the people living and working in the nursing home, listening to their views and concerns.
The reluctance of the care staff to engage in the research was a major issue, which raises an ethical question about how far an academic researcher should encourage apparently disinterested people to participate, even if the project aims to improve aspects of their lives. Critics of participatory practices refer to the ‘tyranny of participation’ and the dangers of tokenism whereby control over the agenda for change is never really shared, and traditional power holders (policy-makers, managers and academics) remain dominant. In this case we might ask whether the pressure on care workers to participate in the research could reinforce their feelings of being relatively powerless and being used to meet managers’ and academic researchers’ goals, as opposed to being offered a genuine opportunity to have a say in improving conditions in the home for residents and themselves. On the other hand, if the care workers were absent from the research, how meaningful would the research be and would the care workers feel further side-lined and excluded? This dilemma is implicit in the case, although not discussed as such by the author.
In fact, the researcher’s persistent and careful work with the care workers seems to have paid off as they started to talk together and developed plans for new activities with the residents. Behind this we catch a glimpse of the complex role of the academic researcher as a group facilitator, community builder, mediator of conflict and creative artist. The intricate ‘ethics work’ on the part of the academic researcher to engender trusting and respectful relationships and include different people and ideas is hidden behind the scenes. But it helps explain the sense of regret expressed in the final paragraph of the case, not only that the research could not proceed as planned due to Covid-19 restrictions, but also that the researcher did not continue her relationships with the people living and working in the home.
This feeling of regret is the main ethical point of the story as presented by the author: that she felt she had failed in her ‘duty’ to support the care home during the difficult period of Covid-19. Her sense of responsibility is not directed towards the expectations of the research funder or the University, but rather the people living and working in the home. She specifically refers to her identity as a ‘participatory researcher’, which means ‘I am also an activist’. The sentiments expressed in the final paragraph signify a deep sense of moral regret. What philosophers call ‘agent-regret’ entails a process of negative retrospective assessment by someone who acted/failed to act in the past, shaped by their attachment to a project or end (Wallace Citation2013, 15–77). The retrospective assessment is exemplified here by the comment: ‘looking back I think I should have supported the home’. The relevant attachment is to the identity of ‘participatory researcher’, which entails being an activist (that is, working for positive social change).
One feature of agent-regret is that moral agents still feel regret even if they judge they made the right decision in the past, or no other alternative was available (ibid). The academic researcher does not give details of an actual decision not to try to pursue some kind of research or activity in the home during the Covid-19 restrictions. It seems that the postponement of the research was accepted as inevitable, and alternatives such as paying for improved internet access and digital technology were either not considered or were judged to be unfeasible. Given the stress and risks associated with Covid-19 in residential homes, this could be judged as a reasonable response. Applying utilitarian principles, the balance of harms and benefits of pursuing the research in another way could easily be argued to lie in favour of stopping the research project. Even if residents, relatives and staff were trained in the use of digital technology and would benefit from greater contact with each other, relatives and carers, the burden on the already stressed staff would have been regarded as too great. But regret does not depend on rejecting judgments made in the past, it derives from feelings of sadness and disappoinment at the ways things turned out, often accompanied by guilt, as in this case.
While engaging in a process of ethical reasoning based on utilitarian or deontologial principles (weighing up the balance of harms and benefits or respecting people’s rights to dignity and choice) may offer an impartial, rational justification for the postponement and then ending of the research, this would not necessarily assuage the academic researcher’s sense of regret. For the regret derives from a personal attachment to the identity of ‘participatory researcher’, and to this reseach project, neither of which could be realised. The framing of the case by the author is not in terms of ethical reasoning and justification drawing on principle-based ethics, although in the commentary I have drawn out what some of the lines of ethical argument might be for engaging the care workers and postponing/ending the research. Rather, it is in terms of the researcher’s relationships to the other stakeholders in the project, and her sense of her identity, roles and responsibilities. Relational concepts from the ethics of care (such as attentiveness, responsibility, competence and trust) and character-based ideals from virtue ethics (being a good person/participatory researcher and living up to one’s ideals and projects) seem particularly pertinent in this case, as in participatory research more generally (Banks and Brydon-Miller Citation2019, 10–14).
For many people, the experience of living and working through the Covid-19 restrictions on human contact has highlighted the importance of relational roles and responsibilities, and engendered a sense of loss or even damage (including ‘moral injury’) to important aspects of themselves and their identities as good and caring people. While decisions and actions can be justified based on rational arguments, which weigh rights, risks, harms and benefits, the sense of regret for what was lost or left undone remains and is important as a way of holding onto important features of our ethical identities, ideals and projects.
Acknowledgements
The first case was submitted as part of a survey on ethical challenges for social workers during Covid-19 conducted by the Social Work Ethics Research Partnership in May 2020 (see Banks et al. Citation2020). Thanks to the social worker who gave permission for it to be published (anonymously for reasons of professional confidentiality) in this journal. The research was funded by Durham Unversity through the Economic and Social Research Council Impact Acceleration Account (reference ES/T501888/1). The second case was written in response to a call via the Ethics Working Group of the International Collaboration on Participatory Health Research in June 2021.
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Notes on contributors
Sarah Banks
Sarah Banks is co-director of the Centre for Social Justice and Community Action and Professor in the Department of Sociology, Durham University, UK.
Marilena von Köppen
Marilena von Köppen is research assistant and PhD candidate in the Department of Nursing and Health, Fulda University of Applied Sciences, Germany.
References
- Abma, T., S. Banks, T. Cook, S. Dias, W. Madsen, J. Springett, and M. Wright. 2019. Participatory Research for Health and Social Well-Being. Cham, Switzerland: Springer.
- Banks, S., and M. Brydon-Miller. 2019. “Ethics in Participatory Research.” In Ethics in Participatory Pesearch for Health and Well-Being, edited by S. Banks, and M. Brydon-Miller, 1–30. London: Routledge.
- Banks, S., T. Cai, E. de Jonge, J. Shears, M. Shum, A. M. Sobočan, K. Strom, R. Truell, M. J. Úriz, and M. Weinberg. 2020. “Practising Ethically During Covid-19: Social Work Challenges and Responses.” International Social Work 63 (5): 569–583.
- Wallace, R. J. 2013. The View from Here: On Affirmation, Attachment, and the Limits of Regret. Oxford: Oxford University Press.