Care leaders safeguarding the rights of care home residents during COVID-19: Moral failures offering moral lessons

The devastating impact of the COVID-19 pandemic on residential care for older persons was a topic of discussion during a recent meeting of Devon care home owners, researchers and educators. Locally and globally, the pandemic had a particularly catastrophic impact on older adults in residential care and their families and friends. Care-givers and care leaders were also significantly impacted negatively as they struggled to deliver care and support in uncharted and most challenging circumstances. It has been argued that our societal failure to learn lessons from previous pandemics leads to failures which ‘should be understood as moral failures that offer moral lessons’.¹ Our aim in this Editorial is to stimulate discussion regarding the moral lessons that follow from failures upon the residential care sector during the COVID-19: What have residential care leaders learnt from their experience of the pandemic? What might educators and researchers contribute to support the social care sector prepare for future pandemics?

A report from Amnesty International ‘As If Expendable²; detailed a raft of failings in the United Kingdom administration that contributed to the deaths of care home residents. Between 2 March and 12 June 2020, 18,562 residents died from COVID-19, amounting to 40% of all deaths. Failings included: ‘mass discharges from hospitals into care homes of patients infected or possibly infected with COVID-19’; failure to advise or provide personal protective equipment (PPE) to care homes; failure to ‘assess care homes’ capability to cope with and isolate’ people infected and lack of support to respond to emergency situations; failure to provide regular testing of care home residents and staff; ‘imposition of blanket Do Not Resuscitation (DNAR) orders on many residents’; and suspension of regulatory activity designed to provide protection for care home residents, for example, from the Social Care Ombudsman and the Care Quality Commission.²

Readers of this journal will be acutely aware of the tension which exists, during a pandemic, between public health ethics which is necessarily focused on population health and care ethics and human rights perspectives which focus on individual persons. The failings listed above do not then fully capture the human cost of pandemic restrictions on care home residents’ relationships with families and friends. A recent paper by Clayton O’Néill³ does just this by detailing the story of ‘Janet’ which brings to the fore the suffering of care home residents deprived of meaningful contact with loved ones. Janet’s story details a happy pre-pandemic life with regular visits and outings with a loving niece to a pandemic existence when ‘she lost her grip on life and the purpose of life […] a life ‘without love unforgiving in its brutality’.³ As Arthur Frank writes:

Stories animate human life; that is their work. Stories work with people, for people, and always stories work on people’. Stories affect ‘what people are able to see as real, as possible, and as worth doing or best avoided⁴

The stories shared during our meeting in Devon regarding care home leaders and their experiences of the COVID-19 pandemic were wide-ranging, most predominantly referring to the selfless dedication and efforts of care home staff to protect residents. One care home owner shared the devastating impact of residents’ deaths and of the importance of care home leaders ‘rolling up our sleeves’ enacting a ‘determined, confident and strong approach’ and showing the team that, despite the significant challenges, there remained much to be proud of. Another care home owner highlighted the importance and positive impact of nurses ‘taking a stand’ during the pandemic. Their discerning and cautious approach to only admit people from hospital (for example, with negative Covid-19 tests) helped result in fewer infections and deaths than in some other care homes:

‘The conflicting advice given by government suggesting that Covid wasn’t likely to be infectious to older people - and that it was safe to admit infected people brought into the homes from hospital - was farcical. Anyone who is infections from an air borne virus will potentially spread it to others, unless significant measures (beyond those available in a non-hospital setting) are in place. Why were social care homes pressured into doing this? And why did the nurses accept this pressure as being OK? Nurses in the Health, Social Care and Governmental and regulatory bodies should go back to the established evidence before acting upon contradictory pandemic guidance geared to protecting the NHS, seemingly having priority. Yes, they could have stepped up and said ‘no’, not unless the correct protections and comprehensive measures were put in place (but which were not available). One must question whether systemic adherence to contradictory guidance was reasonable or was it due to a lack of education, and/or seemingly having to go against their better instincts?’

The stand taken by care home leaders in our discussion group was courageous and praiseworthy, particularly at a time when there was much uncertainty and pressure to support hospital discharges. There have, then, been positive achievements regarding care home leaders innovative responses to adversity.

Arguably there were also missed opportunities for nurses, and other care leaders, to have done more to enact advocacy and allyship in relation to older people, rather than follow contradictory guidance. Arguments suggest an ‘(over-) heroization’ of nurses’ work⁵ calling into question nurses’ commitment and ability, during the pandemic, to enact social justice. Whilst there is evidence of supererogatory efforts of many nurses working with older adults, there is also anecdotal evidence of insensitivity and possible abuses of power which increased the suffering of older people and their loved ones in following such guidance.

The moral lessons that follow from moral failures require open and honest engagement from key stakeholders. They require a slow approach characterised by, among other elements, the enactment of ethical sensitivity, a commitment to solidarity and engagement with stories.⁶ They include also making space to plan and operationalise practice-based strategies that put older people and their loved ones first and innovative educational approaches which prioritise the cultivation of character in care. To that end, we are collaborating in the development of a Massive Open Online Course (MOOC) on this theme which will be available in early 2023.

The moral failures upon residential care have been framed as violations of human rights. As O’Neill ³ writes:

‘…the rights of residents in care homes were not protected with appropriate care, caution, courage and concern. Whilst there was a need to protect life and the restrictions on visitation might have been justifiable, for the most part, individual autonomy was not upheld sufficiently. That is not something of which we can be proud.’

The first article in this issue details the moral failures experienced in residential care, in a European country, during the pandemic and efforts made to strengthen the moral community of older persons needing care, their care partners and professional care-givers.⁷

Regarding the contribution of educators and researchers to support the social care sector to prepare for the next pandemic – and there will be future pandemics – we agreed that a focus on virtue and care ethics perspectives are critical at a local, national and international level. There needs to be pride in care practices, courage and practical wisdom in leadership and serious engagement across the Health and social care system with previous failures, with a commitment to do better in future. Critically, there needs to be a mobilisation of the sector to effectively pressurise politicians and regulators to plan now so the same failures are not repeated. The lessons we need to learn include being proactive in creating meaningful collaborations to listen to and include the voices of residents, their loved ones, care-givers, care providers and care sector leaders, educators and researchers. Collaborations which will lead to innovative strategies to ensure as far as possible that, in the next pandemic, there will be no ‘Janet’s’ and all receive the system support, love and care they deserve.