“We Had Unexpected Reactions from Everywhere”: A Qualitative Study on the Impact of the COVID-19 Pandemic on Supported Accommodations for People with Serious Mental Disorders

Abstract

Background

Limited information is available on the impact of the COVID-19 pandemic on supported accommodations (SAs) for people with serious mental disorders. A quantitative study recently conducted in Portugal showed that these services struggled with a more challenging environment, residents’ fears, and a lack of support from community services. We now aim to complement it by reporting qualitative data on the experiences of residents and professionals of SAs for people with serious mental disorders during the pandemic.

Methods

A purposive sample of 11 residents and 11 professionals from 11 different organisations responsible for SAs in Portugal was included. Data were collected through semi-structured interviews. The interview guide included questions regarding changes in the functioning of SAs and implemented measures during COVID-19 and the impact of the pandemic on the well-being of residents and professionals. Thematic analysis was used.

Findings

Some SAs had to close or relocate, and several procedures were changed. Residents felt that the most impactful changes included not being able to go outside or see loved ones. Despite some residents reporting anxiety or sadness, almost none relapsed. However, some professionals noted an impact on the autonomy and cognition of residents. Despite reporting a negative impact of the pandemic on their own well-being, professionals struggled to maintain the functioning of SAs and the well-being of residents. Residents recognised the effort made by professionals and felt supported by them during COVID-19.

Conclusions

The COVID-19 pandemic significantly impacted the functioning of SAs. In line with our findings, some actions seem fundamental to improve SAs’ resilience in the future. These relate to human resources, training, structural conditions, new technologies, and professionals’ well-being.

Highlights

• COVID-19-affected supported accommodations (SAs): many procedures changed, at least transiently, and some SAs had to close or relocate.

• Residents were resilient but had impairment of their autonomy.

• Despite reporting a negative impact on their well-being, SA’s professionals made a huge effort to maintain the functioning of SAs.

• More is needed to improve professionals’ and SAs’ resilience in the future.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has affected mental health care worldwide [1–3]. Many health services had to decrease activities or close altogether [1–3]. Despite the general impact on health care, its effects have probably varied across different health settings. Supported accommodations (SAs), in particular, are specific services that provide a complex type of care and merit special attention. SAs provide residential support, ideally in the community, for people with serious mental disorders (SMD) and complex needs [4, 5]. They support people in their recovery process, promoting the development of living skills, autonomy, and social inclusion [6, 7].

Despite the uniqueness of SAs, very few studies have been conducted on the impact of the pandemic on these services [8–15]. These studies supported, nonetheless, the widespread impression that SAs faced many challenges in delivering care, including the need to cancel many activities and reduce contact between workers and residents [10–14]. SAs struggled with infection control and a more challenging environment due to residents not being able to go out and engage in activities [10, 11]. Some studies reported that residents presented none to mild symptoms of anxiety and depression [8, 9], but others reported greater anxiety and irritability [8, 9, 11, 13]. Workers experienced fear, higher workload, and feelings of unpreparedness [12, 14]. Finally, there were descriptions of the strategies implemented to tackle the pandemic, such as delivering digital care [11, 13]. Despite providing important information, most studies did not focus specifically on SAs, some did not use formal research methods, and others focused solely on the workers’ views.

The SAPORT (“Supported Accommodations in Portugal”) research aimed to analyse the functioning of SAs for people with SMD in Portugal [16]. Part of this research intended to explore the impact of COVID-19 on these services. Among the quantitative findings of the effects of the pandemic on SAs according to the professionals’ perspectives, reported work challenges included a challenging environment (owing to the restrictions that prevented residents from going out and engaging in activities), residents’ worries about COVID-19 infection, and a lack of support from community services [17]. In addition, an overall negative impact of COVID-19 was reported by 26.5% of professionals, who felt that they were less able to do their job than usual due to the stresses of the pandemic, and 43.6% of professionals perceived a deterioration in the mental health of residents.

To complement this quantitative approach, we decided to use a qualitative approach and explore not only the experiences of professionals but also of residents of SAs during the pandemic. In the present study, we therefore aimed to analyse in-depth the experiences of professionals and residents seeking for important lived experiences on how SAs coped with the pandemic and on successfully implemented strategies during COVID-19. This kind of in-depth exploration has not been attempted in Portugal, and more data are needed internationally. Although some time has elapsed since the pandemic, more robust information about how COVID-19 affected services remains fundamental to identifying systemic vulnerabilities and areas for improvement, optimising the delivery of care, and fostering resilience to safeguard services against future public health crises.

Methodology

Study Design, Context, and Population

This study was conducted on residents and professionals of SAs for people with SMD in Portugal. These services differ mainly according to the type of support provided, ranging from maximum support, where residents present high levels of disability and in-person support is provided 24 h/day, to minimum support, where residents present low levels of disability and in-person support is usually provided a few hours per week. These units are run by non-governmental organizations, religious orders, and the National Health Service. In many cases, more than one SA is run by the same organization. There are significant disparities regarding the type of support provided and the geographical distribution, with most SAs providing moderate support and located in the Lisbon Metropolitan Area. We identified all the existing SAs in the country through contacts with the Ministry of Health, religious orders, and public psychiatric hospitals and using the Website “Carta Social” [18].

Sixty SAs were identified and invited to participate in the SAPORT research. In total, 42 SAs, belonging to 16 different organisations, agreed to participate (response rate = 70%). For the present study, and due to human resources constraints regarding the research team, we included a purposive sample of 11 residents and 11 professionals from 11 different organisations. It must be noted that the organisations included were responsible for most of the national SAs and reflected the national disparities regarding the type of support and location of SAs. Inclusion criteria for residents were admission at least 6 months before March 2020. Those presenting intellectual disability or moderate or severe acquired cognitive impairment were excluded. Regarding professionals, inclusion criteria were having coordinating tasks, preferably over more than one SA, and having been working at the SA(s) for at least 1 year before the beginning of the pandemic. Those who had been working at the SAs for less than 1 year before the pandemic were excluded. All eligible participants were provided with information on the study and invited to participate.

Ethical Considerations

This study was approved by the Ethics Committee of NOVA Medical School of the NOVA University of Lisbon (172/2021/CEFCM). Written informed consent was obtained from every participant, and data confidentiality was guaranteed.

Data Collection and Analysis

Semi-structured interviews were conducted. The interview guides were developed by the research team and pilot tested in two different SAs. It included questions about the SAs’ functioning during COVID-19, implemented measures, changes in the participants’ daily lives, and the impact on their well-being. The interviews were conducted by the first author, who did not have a relationship with the participants before this study. The interviews were conducted between February and July 2022 and lasted from 17 to 103 min (median = 46.5 min).

All interviews were audio-recorded and transcribed verbatim. Meaning saturation was considered when participants presented no additional new data and when research questions were comprehensively addressed. Reflexive thematic analysis was used to analyse data [19, 20]. Reflexive thematic analysis allows access to participants’ experiences and is also compatible with critical qualitative research. Pivotal to this method is the notion that the researcher is central to the process of analysis, and its subjectivity is a key tool to actively use. In line with this notion, and using an inductive approach, the analysis of data was conducted by the lead researcher. A first initial process of getting acquainted with data by reading and re-reading transcripts, reflecting, writing notes to increase familiarity, and interpreting these was conducted. This was then followed by the generation of initial codes, which resulted from an organic and subjective process, in line with the interpretative reflexive process described by Braun and Clarke [19, 20]. Initial themes, defined as patterns of shared meaning connected by a main idea, were then created from coded data. These were subsequently reviewed and refined into final themes. The process of analysis was not static, but iterative, as the researcher revisited the process as necessary. Although the initial themes were developed by the first author, they were subsequently reviewed, discussed, and refined collaboratively by all co-authors to ensure the rigour of the analysis. MAXQDA software was used to facilitate the process of analysis [21]. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist guided the reporting of these findings [22].

Results

All interviews were completed as planned.

Residents

The characteristics of the participating residents are presented in Table 1. Three themes resulted from the analysis of the residents’ interviews: “our day-to-day completely changed,” “the impact on our well-being and health,” and “professionals and strategies to deal with the pandemic.” Quotes were selected to exemplify each theme, below (see also online suppl. Table 1; for all online suppl. material, see https://doi.org/10.1159/000551736 for a more complete overview).

Table 1.

Characteristics of the participating residents

Characteristics of the participating residents	n (%)	Mean (SD)
Gender
Male	6 (54.5)	​
Female	5 (45.4)	​
Age, years	–	54 (9.6)
Diagnosis1
Schizophrenia or related psychosis	9 (81.8)	​
Bipolar disorder	1 (9.1)	​
Asperger’s syndrome	1 (9.1)	​
Length of stay	–	8.18 (5.3)
Type of support offered by the SAs of residents
Minimum	2 (18.2)	​
Minimum to moderate2	2 (18.2)	​
Moderate	5 (45.5)	​
Maximum	2 (18.2)	​
Location of the SAs of residents3
North	2 (18.2)	​
Centre	2 (18.2)	​
Lisbon metropolitan area	5 (45.4)	​
South	1 (9.1)	​
Insular Region	1 (9.1)	​

¹Diagnosis: according to medical records.

²Type of support offered by the SAs – minimum to moderate SAs refer to the more recently created autonomy training SAs, which provide intermediate support between minimum and moderate.

³Location of the SAs: regions in Portugal.

Our Day-to-Day Completely Changed

The first theme reflects the reported changes in the residents’ daily lives during the pandemic. In general, residents reported that their daily lives changed dramatically with the pandemic. Not being able to go out was the most impactful change reported. For those relocated to hospital grounds, this seems to have been particularly difficult. According to residents, restrictions on going out seem to have been different across different SAs and pandemic periods. While most did not report any change in the SA’s environment, two participants reported a challenging environment. Reportedly, restrictions on seeing family and friends were also challenging. With the gradual improvement of the pandemic and vaccines’ availability, some reported being allowed family visits.

“It changed because we cannot go out (…) we don’t have the freedom to go out (…) we feel…imprisoned.” (Resident (R) 4)

Residents also reported a change in daily activities. Before COVID-19, many attended socio-occupational units outside the SAs, but with the pandemic, these units closed, at least for some time. Other outdoor activities were also interrupted. Some residents reported having been without occupational activities for some time, but most stated that, eventually, SAs started promoting indoor activities, such as board and card games, quizzes, requested music, movie sessions, reading, drawing, and physical activities. For a few, activities were delivered online and were usually accessible to all residents of a given organisation, allowing people from different units to maintain contact. Some residents reported having continued their usual household chores, but others stopped some chores, namely, cooking. For some, these helped pass the time.

Impact on Our Well-Being and Health

The second theme reflects the reported changes in the health of residents. Most residents reported having felt afraid and anxious about COVID-19, but this seems to have reduced over time with the availability of vaccines. Some referred that the pandemic caused them anxiety or sadness, mostly due to not being able to go outside and be with their families. One participant reported a negative impact on her autonomy. Despite this, most reported that, in general, the pandemic did not affect their mental health significantly. Actually, a few reported that the pandemic improved their well-being.

“…when (…) there was still no vaccine…it made me a bit anxious (…) I was afraid to catch it (…) from the moment when there was a vaccine (…) I don’t have as much fear…” (R3).

In terms of physical health, some residents reported weight gain due to greater inactivity. Most residents did not report any problems with access to medical care.

Professionals and Strategies to Deal with the Pandemic

The third theme reflects residents’ opinions on the professionals’ performance. Most residents felt that the professionals did a good job during the pandemic and felt supported by them. Many acknowledged it was not easy for professionals. They reported that professionals also suffered from fear and stress, struggled to combine personal and work lives, had a greater workload, and had to invent “a new way of working.”

Most residents thought that the implemented strategies to deal with the pandemic in the SAs were effective, namely, using a face mask, washing hands frequently, indoor activities, going for walks outside, or going to pavement cafés with the professionals. Regarding preventive measures, such as face masks, despite initially struggling, most eventually adapted and understood the need.

“…the written quizzes, the hygienic walks (…) going to the pavement café with the professionals (…) I think it was the most productive (…) it occupied the mind…” (R3).

Although some participants thought that some caution should be maintained, most felt SAs should go back to their normal functioning as soon as the pandemic situation improved and wished to be “free.”

Professionals

The characteristics of the participating professionals are presented in Table 2.

Table 2.

Characteristics of the participating professionals

Characteristics of the participating professionals	n (%)	Mean (SD)
Gender
Female	11 (100)	​
Profession
Psychologist	4 (36.3)	​
Social worker	3 (27.3)	​
Psychopedagogist	2 (18.2)	​
Mental health nurse	1 (9.1)	​
Occupational therapist	1 (9.1)	​
Years working in mental health	–	18.3 (9.4)
Number of professionals coordinating more than one SA	6 (54.5)	​
Total number of SAs coordinated by the professionals	27	​
Number of SAs coordinated by the professionals according to the type of support offered
Minimum	6 (22.2)	​
Minimum to moderate1	5 (18.5)	​
Moderate	14 (51.9)	​
Maximum	2 (7.4)	​
Location of SAs coordinated by the professionals2
North	7 (25.9)	​
Centre	5 (18.5)	​
Lisbon metropolitan area	12 (44.4)	​
South	1 (3.7)	​
Insular Region	2 (7.4)	​

¹Type of support offered by the SAs – minimum to moderate SAs refer to the more recently created autonomy training SAs, which provide intermediate support between minimum and moderate.

²Location of the SAs: regions in Portugal.

Four themes resulted from the analysis of the professionals’ interviews: “everything changed,” “it was hard on us,” “residents’ resilience surprised us,” and “not all was bad and tools that helped us navigate the storm.” Quotes were selected to exemplify each theme, below (see again online suppl. Table 1 for a more complete overview).

Everything Changed

The first theme reflects the reported changes in the functioning of SAs. According to professionals, some SAs “had to open more than ever” as residents had to stay mostly indoors. However, others closed or relocated residents due to fear of infection, staff shortages, or lack of structural and financial conditions for isolation and personal protective equipment (PPE). In the case of two SAs run by non-governmental organizations, one closed and sent residents home, and the other relocated residents to another community unit within the same organisation. In the case of 5 SAs run by religious orders, residents were relocated to units on hospital grounds. In the opinion of many, residents should not have returned to the hospital as the risk of infection was not decreased.

“…one unit, ok, got COVID (…) which (…) led the institution itself to question the validity of this measure [returning to the hospital], right? Looking back, and knowing what we know today, maybe things could have been done a bit differently…” (P6).

Professionals reported having to continuously develop contingency plans, change procedures, namely, hygiene-related, and promote education on COVID-19. Visits were often discontinued. Reportedly, tasks usually carried out by residents before the pandemic shifted to professionals, which meant that, at least initially, occupational activities for residents were stopped. Over time, many SAs reportedly focused on the use of new technologies, organising activities and meetings online.

“…they stopped doing everything, they stopped doing the cleaning because they made us do the disinfections (…) they stopped preparing meals, stopped cleaning the spaces, stopped going out to buy tobacco, stopped going out to buy medication, stopped going out to buy hygiene products, stopped having occupational activities (…) their day to day changed, they were locked, confined…” (P10).

The usual connections to the community were reportedly suspended, delaying possible discharges to more independent living. The connection to mental health services was generally maintained, mostly via digital means. While many considered this was most useful, some argued the return to in-person appointments was overdue. The connection to other medical services was reportedly more difficult, with many appointments cancelled.

It Was Hard on Us

The second theme reflects the difficulties and the reorganisation of the workforce. In the beginning, professionals reported fear and anxiety. There were “all human reactions, expectable and non-expectable… the best and the worst of each one came to the surface.” Reportedly, many people took sick leave, and others quit their jobs. Others continued to work but were “disconnected.” Together with COVID-19 infections and unit separation, the available workforce decreased significantly.

“We had unexpected reactions from everywhere. (…) we went through everything because there was a lot, especially in the beginning, there was a lot of fear, there were people who took a sick leave (…) all the arguments and all the plausible and non-plausible situations…” (P1).

The increased demands reportedly compelled the workforce to restructure in different ways. Many adopted “split-team” schemes, others remote work, or longer working hours. For some, remote work was not possible due to job demands or a lack of new technologies or training.

Professionals reported having made a huge effort to implement the necessary ever-changing adjustments and maintain residents’ well-being while managing their own family needs. Some professionals reportedly had to provide support to other units and undertake tasks that were not usually theirs and for which they were unprepared, namely, safety and hygiene-related tasks. This effort took a toll on the professionals. Many reported having felt “strengthless,” “emotionally and physically drained,” burned-out, and “exhausted.” Some felt that the pandemic had inevitably changed them. Others felt their organisations failed to support them.

“We the technical team also integrated to do...to go to one unit and provide whatever support was needed (…) and it was very stressful. (…) I remember there were days when I got home and I would have crying spells, and out of nowhere, I mean, it was weariness, tiredness and also because I was working in an area that wasn’t mine (…) I did all that was necessary to do, dressing the residents, help them eat, waiting tables…” (P8).

Residents’ Resilience Surprised Us

The third theme reflects the professionals’ perspectives on how residents reacted to the pandemic. According to professionals, initially, many residents felt anxious about the pandemic. Despite professionals’ initial fears, reportedly, almost no residents relapsed. The only two described cases occurred in units that relocated to hospital grounds. Overall, professionals were surprised by the resilience of residents.

“I thought at the beginning that they would all relapse (…) and nothing of that happened.” (P2).

“…one resident (…) had several crises, even got less functional than what she was before, did not want to return outside [to the SA in the community]…” (P8).

Inactivity and weight gain were reported as negative impacts of the pandemic on residents. Many also noted an impact on residents’ autonomy and cognition. Identified reasons included lack of stimulation, isolation, and fewer daily tasks. However, not all felt this negative impact. Some felt residents’ quality of life improved because they had fewer responsibilities.

Not All Was Bad and the Tools That Helped Us Navigate the Storm

The fourth theme reflects that despite all difficulties, many professionals also recognised positive changes due to the pandemic, such as SAs being open all day long; new contracts; new technologies; improved procedures; and better human relationships.

“…it was a good excuse to change things for the better, namely disinfection and hygiene procedures…” (P2).

Reportedly, new technologies helped overcome the lack of activities and social isolation and maximised time and human resources. A “clear” and “transparent” communication, shared decision-making, and basing decisions on official recommendations were essential to better handle the situation. All these efforts increased the cohesion of the team, which ultimately was key to navigating the pandemic. Finally, many reported open-air spaces were fundamental to overcoming inactivity, and new working contracts or trainees, such as nursing students, helped tackle the lack of professionals.

“…regarding the residents, I think it was very important and very effective (…) the sense of safety they felt and that we transmitted. (…) Concerning human resources, I think the importance of communication (…) of them being aware of what is happening…” (P10).

A summary of the participants’ main reported topics is presented in Table 3.

Table 3.

Summary of the participants’ main reported topics

Residents	Professionals
Our day-to-day completely changed	Everything changed
Their daily lives changed dramatically They had to spend most time in the SAs, with many having felt locked inside. There were many restrictions to go out. This was particularly difficult for those relocated to the hospitals Restrictions varied between SAs and different pandemic periods Most did not report any change in the environment except for two, which reported a more challenging environment Restrictions to seeing family and friends were also challenging. With time some were allowed to see their families. Some were not allowed to see friends Their daily activities changed. Socio-occupational units closed and other outdoor activities were interrupted, leaving residents without occupation SAs eventually started delivering activities indoors. For some these were delivered online, allowing them to be in contact with residents from other services Some continued their usual chores, but some residents stopped some chores such as cooking	While some SAs “opened more than ever” due to residents having to be indoors, others closed and relocated residents to other units due to fear of infection, lack of human resources, and structural and financial resources Many felt that residents should not have been relocated to the hospitals, as this did not decrease contagion They had to continuously develop contingency plans, change procedures, and promote educational sessions on COVID-19 Family visits were often discontinued Many tasks carried out by residents before the pandemic, shifted to professionals Occupational activities stopped at the beginning Over time, many SAs focused on the use of new technologies Connections to the community were suspended, delaying possible discharges to more independent living. The connection to mental health care was generally maintained through new technologies. The connection to other medical care was more difficult
The impact on our well-being and health	Residents surprised us
Most reported fear and anxiety about COVID-19, which subsided over time Some reported having felt anxious or sad because they could not go out, see their family, or because they saw their colleagues getting ill One reported an impact on her autonomy The majority did not feel any significant impact on their mental health A few actually reported an improvement in their well-being	Initially, professionals felt residents were anxious about COVID-19, but eventually they grew weary of it Despite initial fears, professionals mentioned almost no resident relapsed. The only two reported cases occurred in residents who relocated to hospital grounds Overall, residents were considered very resilient Some reported negative impacts, which included weight gain, inactivity, loss of autonomy and cognition impairment Some felt residents’ quality of life had improved due to having fewer responsibilities Most felt returning to normal was taking time
The professionals and their rules	It was hard on us
Most residents felt that the professionals did well during the pandemic and felt supported by them. In some cases, the relationship with professionals even improved Residents thought the pandemic was also difficult for professionals, who had to invent a “new way of working” They thought the implemented strategies to deal with the pandemic were useful, namely using face masks, hand hygiene, indoor activities, going for outside walks or to pavement cafés. Most understood the need for preventive measures Although some thought that caution should be maintained, most felt the SAs should go back to their normal functioning when the pandemic situation improved	Professionals often felt fear and anxiety at the beginning, with many taking sick leaves and others resigning Due to the increased demand and staff shortages, they had to reorganise the workforce in different ways, such as splitting teams, increasing working hours or embracing remote work Some had to uptake tasks for which they were not prepared and provide support to other services Professionals struggled to deal with necessary changes and balance work and family life Many felt burned out and exhausted and some felt their organisations failed to support them
​	Not all was bad
	Many acknowledged positive things resulted from the pandemic, namely SAs being open all day, new contracts, the use of new technologies, improved procedures, and better human relationships
	Tools that helped us navigate the storm
	The use of new technologies, a clear communication, involving all professionals in the decision-making process, making decisions based on official recommendations, team cohesion, open-air spaces, and new working contracts and trainees, were very important to handle the pandemic situation

Discussion

We found that, due to COVID-19, several changes occurred in SAs: some closed or relocated; procedures were drastically altered; occupational activities were halted; professionals had to constantly revise contingency plans and struggled to maintain SAs functioning; most residents denied a considerable impact on their mental health, but professionals felt the autonomy and cognition of some were affected. Nevertheless, some participants believed the pandemic improved certain aspects of SAs, namely, hygiene-related procedures and the use of new technologies.

According to the participants, the stringency of implemented measures seems to have been different across SAs. In particular, the closure or relocation of SAs meant that residents had to move into potentially worse living conditions. The relocation to hospital grounds seems to have been particularly difficult for residents compared to any other measure. Comparable to other services worldwide [1, 3], these professionals reported several constraints, namely, unpreparedness, staff shortages, and lack of PPEs. This may partly explain why SAs responded so differently and also why this did not seem to relate to the type of support SAs. Other reasons may include guidance from different health authorities, architectural reasons, fear, or even stigma. Despite the underlying reasons, more restrictive measures did not avoid contagion and had a negative impact on the participating residents. Moreover, unpreparedness and staff shortages meant that these professionals were unable to deliver activities for residents, possibly compromising rehabilitation programmes. According to these professionals, and as in other SAs [12], the pandemic hindered access to general health care. Interestingly, most residents denied constraints in access to health services, possibly because these did not need medical attention or because the professionals were the ones securing medical care. In general, telepsychiatry ensured the connection to mental health services. However, there were inequalities in the accessibility and quality of care due to a lack of new technologies or training, a concern also raised in other studies [23, 24]. Moreover, in some SAs, limited space hindered privacy during digital consultations, and some professionals felt telepsychiatry did not allow them to fully understand how the resident was doing, a vision shared with providers elsewhere [23].

Seemingly, residents’ mental health was not considerably affected. Being used to some restrictions in their lives, continuity of care, and withdrawing from stressful situations have probably contributed. Feeling supported, that the professionals were able to manage the challenges brought by COVID-19, indoor activities, and controlled outside activities were all felt as positive and also probably played a part. This is aligned with studies in which participants showed great resilience [8, 9]. However, it contrasts with our previous quantitative study, in which circa 40% of professionals perceived a deterioration in residents’ mental health [17]. The inclusion of mostly professionals without training in mental health in the abovementioned study or selection bias towards more resilient residents or social desirability bias in the present study may explain this difference. The reported negative impact on weight, autonomy, and cognition in some residents is worrisome and probably resulted from inactivity and isolation, but further research is advised. Aligned with other studies, including our previous one, these professionals’ well-being was affected [17, 25–27]. Issues raised by many of these professionals, such as higher work stress, lack of training, and lack of support at work, have indeed been associated with worse well-being and an increased risk of burnout during COVID-19 [25, 26, 28]. Being mostly female and culturally having major roles in family chores may have also contributed [29, 30].

Similar to other studies [14, 24], many professionals recognised effective strategies, such as communication, shared decision-making, official guidelines, open-air spaces, and increasing human resources. Indeed, new technologies were used worldwide and allowed to liaise with other services, provide therapeutic activities, decrease isolation, and maximise time and human resources [1, 14, 24]. Receiving reliable and timely information and feeling supported at work have been associated with better mental health during COVID-19 [25, 31]. Although the participating residents did not find any silver lining, most found the implemented strategies effective, namely, safe indoor and outdoor activities. Similar to another study [14], most residents understood the need for safety measures, which should reinforce confidence in their capacity to understand and comply with rules.

To our knowledge, this is one of the few studies on the impact of the pandemic on SAs internationally and arguably the most in-depth perspective on the experiences of SAs professionals and residents during COVID-19. Although conducted in a single country (Portugal), one major strength was to include participants from different SAs, with various types of support, and from diverse regions. Due to the variation of SAs worldwide and to most data coming from a small number of SAs in a few countries, having national-level information from different countries is fundamental to better understanding the impact of COVID-19 on these services and preparing for future emergencies. However, our study is also with limitations. Having been conducted in 2022, it may not provide an entirely accurate picture of experiences during other COVID-19 pandemic phases. Moreover, as the sample was restricted to 22 participants (11 residents and 11 professionals), our findings may not have captured the full diversity of perspectives across other Portuguese SAs or reflect the reality of care delivery in other countries. Some of the participants’ characteristics may have influenced their perception of the pandemic. Therefore, and due to the qualitative nature of this study, caution is needed regarding generalisability.

Reflecting on these changes is paramount in the context of COVID-19 and similar challenges to come. Based on the participants’ experiences during the pandemic and the (scarce) literature, we elaborated on some preliminary suggestions (see Table 4). One critical aspect is increasing funding for SAs. This would help to address the lack of modern technologies, essential for combating isolation, offering activities, and maintaining connections with health and community services. Adequate funding would allow SAs to accommodate unforeseen expenses and adapt more effectively to new challenges, such as acquiring PPEs. Improving the collaboration between SAs and other health services and authorities is also fundamental, so that SAs may receive timely and evidence-based guidance from health authorities. Enhancing the physical infrastructure of SAs is also vital. Offering single-room accommodations not only improves residents’ quality of life under normal conditions but is essential for preventing contagion during pandemics. Provided safety measures are assured, visits seem safe and beneficial [32]. Restricting visits is only acceptable during periods of mandatory lockdown, of COVID-19 infections inside the SA, or of impossibility to comply with safety rules. Increasing human resources, promoting training, and staff well-being are also fundamental. Training in emergency procedures and communication can strengthen crisis response and mitigate stigma and fear. In parallel, investing in workplace well-being strategies can reduce absenteeism and burnout, increase motivation, and lower staff turnover. Finally, preparing contingency plans based on the experiences of the COVID-19 pandemic allows services to respond more rapidly and effectively in future situations. Improving the resilience of services enhances routine care and preparedness for future crises.

Table 4.

Suggestions based on the findings of the study

Strengthening SAs with more human resources Preparing for future emergencies (having contingency plans and training professionals may smooth and accelerate the introduction of necessary changes, avoid residents’ inactivity, and promote professionals' well-being) Improving SAs’ structural conditions (to provide the necessary distancing and isolation if needed) Ensuring the availability and the appropriate use of PPE, even outside emergencies Promoting the acquisition, training, and use of new technologies Regulating telepsychiatry (establishing its scope and limitations of use, and ensuring standards of care, privacy, and confidentiality) Implementing work strategies aimed at improving professionals’ mental health and well-being Improving communication at all levels and promoting shared decision-making Ensuring good quality and supportive relationships between professionals and residents at all times (to foster the tranquillity and well-being of residents) Making decisions based on scientific evidence and public health recommendations If needed, restrictive measures should be the least stringent and applied for the minimum time possible Restricting visits only to periods of mandatory stay-at-home orders, periods of COVID-19 infections inside the SA, or when the SA cannot fully ensure safety for all involved (and ensuring residents maintain contact with their relatives and friends at least via new technologies during visiting restriction periods) Promoting safe outdoor activities during emergencies (such as walking or going to pavement cafés) Promoting safe indoor activities during emergencies (online activities may foster socialisation amongst residents from different units and enable a more rational use of resources and thus should be considered) Maintaining safe household chores during emergencies (may be important for the well-being of residents) Safeguarding physical activity and diet appropriateness of residents, at all times Retraining residents’ autonomy and providing cognitive rehabilitative programmes after periods of isolation and inactivity

Conclusion

The COVID-19 pandemic disrupted the functioning of SAs and affected professionals’ and residents’ well-being. Financial and structural constraints, staff shortages, and unpreparedness contributed to a greater impact of the pandemic. On the other hand, new technologies, communication, shared decision-making, following official guidelines, and open-air spaces were helpful strategies. Similar emergencies may occur in the future. Tackling the abovementioned constraints and promoting the reported helpful strategies is fundamental to improving SAs’ resilience for such upcoming situations.

Acknowledgments

The authors would like to thank all the participants for their contribution. We would also like to thank the supported accommodations involved for their support.

Statement of Ethics

This study was approved by the Ethics Committee of NOVA Medical School of the NOVA University of Lisbon (172/2021/CEFCM). Written informed consent to participate in the study was obtained from every participant, and data confidentiality was guaranteed.

Conflict of Interest Statement

The authors declare no conflict of interest.

Funding Sources

The present publication was funded by Fundação Ciência e Tecnologia, IP, national support through CHRC (UIDP/04923/2020). Authors Bárbara Pedrosa and Ugnė Grigaitė were financed by Fundação para a Ciência e a Tecnologia (FCT) (UI/BD/151072/2021 and UI/BD/151073/2021, accordingly) and author Deborah Aluh by La Caixa Foundation (LCF/BQ/DI20/1178001).

Author Contributions

B.P. designed the study, analysed data, and drafted the initial version of the manuscript. G.C., J.C.A., and M.G.P. supervised the study design. B.P., G.C., M.G.P., U.G., D.A., M.S.D., M.S., and J.C.A. contributed to the study design, interpretation of results, and manuscript revision and read and approved the final manuscript.

Funding Statement

The present publication was funded by Fundação Ciência e Tecnologia, IP, national support through CHRC (UIDP/04923/2020). Authors Bárbara Pedrosa and Ugnė Grigaitė were financed by Fundação para a Ciência e a Tecnologia (FCT) (UI/BD/151072/2021 and UI/BD/151073/2021, accordingly) and author Deborah Aluh by La Caixa Foundation (LCF/BQ/DI20/1178001).

Data Availability Statement

The data are not publicly available due to privacy or ethical restrictions. Data are available to investigators outside the Lisbon Institute of Global Mental Health after request and approval by the principal investigator of the original study.