“We Were Just Taking Our Marching Orders and Moving Forward With Whatever We Were Given”: Policy Implications of Pandemic Quarantine and Social Isolation in Older Persons

No one could have foreseen the rapid onset of the novel severe acute respiratory syndrome coronavirus 2 and the resulting complications in an unprepared health-care system. One complication was intensification of social isolation (SI) (Cudjoe & Kotwall, 2020) in response to protective quarantine and lockdown in nursing homes and assisted living centers. This resulted in new or worsening symptoms of depression and anxiety, worsened dementia, feelings of despair, and failure to thrive (Abbasi, 2020; Elmer et al., 2020; Gorenko et al., 2021; Mukhtar, 2020; Plagg et al., 2020; Santini et al., 2020). In response, many state-level aging, disability, and community-based organizations designed and implemented interventions through collaborative public partnerships in attempts to mitigate the negative effects of SI (Advancing States, 2020). For example, Florida’s Department of Senior Services provided robotic companion pets to older persons in SI, persons with disabilities, and caregivers via funding through the Coronavirus Aid, Relief, and Economic Security Act (CARES) Act, passed by Congress on March 27, 2020 (Sontan, 2021). Additionally, Alabama reported the use of innovative approaches, such as weekly check-in calls and virtual social activities, while Arkansas paired staff with volunteers for regular conversations.

No one could have foreseen rapid onset of the novel SARS-CoV-2 and resulting complications in an unprepared healthcare system. One complication was intensification of social isolation (SI) in response to protective quarantine and lock-down in nursing homes and assisted living centers.

While these states have developed collaborative relationships with agencies and community partners, we identified perspectives and needs of older persons and their caregivers living in quarantine to reduce SI (Jumarali et al., 2019) and secured funding through the Oklahoma Shared Clinical and Translational Resource Center (U54GM104938, funded by National Institute of General Medical Sciences [NIGM]-National Institutes of Health [NIH]) Creative Reaction Lab (2021). The project was conducted in metro and outlying areas of Oklahoma City, the 11th largest city in the United States, between May and October 2021, a time when most nursing homes and community services recommended quarantine for older persons (Quigley et al., 2020) and nursing home residents began to decline in health status (Abbasi, 2020; Perez-Rodriguez et al., 2021).

The area consisting of about 687,725 persons was racially and ethnically diverse (Black or African American 14.4%; American Indian and Alaska Native = 2.9%; Asian = 4.4%; Two or more Races = 7.9%; Hispanic or Latino = 20%) (estimations are not comparable to other geographic levels due to methodology differences between data sources). (United States Census, July 1, 2021). In particular, we explored the phenomenon of SI using evolutionary concept analysis (Nicholson, 2009) and we interviewed nursing home residents, family members, nurses, certified nurse aides, directors of nursing, staff at a homeless shelter, nursing home administrators and owners, and public health officials.

Open-ended questions elicited qualitative information about participants’ perceptions of SI among nursing home residents and older persons in the community. All interviews were recorded and transcribed verbatim, and an analysis was conducted (Miles et al., 2014). Graduate students (Boyer, 1990) and the Primary Investigator (RK) listened to recordings and compared each transcript (regular checking and negotiation) until at least 95% agreement was achieved. Completed transcripts were sent to each participant for member checking.

We identified several compelling themes, including communication, loneliness, isolation, and depression.

Communication and Loneliness

The directors of nursing were concerned about communication and socialization strategies and emphasized challenges for internal and external communication: “to keep a reputation that we are caring and taking care of your family.” Further, they were anxious about how to communicate effectively with family members on the “outside” using iPads, and about potential misunderstandings and credibility in communication. Nursing home administrators were also concerned about communication, but mainly from the top down in relation to instructions from leadership and owners: “taking our marching orders and moving forward.”

Isolation

Nurse administrators spoke about residents’ lost freedom and the expectation to monitor activities and compliance, such as wearing masks and social distancing: “we had to monitor them … to ensure … they were wearing … protective personal equipment.” Residents dying alone weighed heavily on caregivers and family members, coupled with the inability to grieve: “dying, without being able … to see them, hug them.” Further, stakeholders recognized loneliness, symptoms of depression, and changes in eating, sleeping, and grooming habits among nursing home residents who “… did not hardly eat.” To sum, one director of nursing stated, “I don’t know if I could have handled much more, you know seeing death like that every day.”

Depression

Helplessness and hopelessness emerged as a central concept of lost communication. Nurse administrators talked about residents experiencing loneliness because of the isolation and strict infection control measures. Nurse administrators also expressed concern about residents losing degrees of autonomy and freedom of choice. Paternalistic actions manifested as perceived seizure of resident control. Further, some stakeholders felt that residents deserved decisional control over activities such as dining with other residents, contact with family and friends, and going home to spend the rest of their lives with family rather than staying in the facility.

Discussion

The pandemic-associated lockdown, shelter-in-place orders, and quarantines deeply affected nursing homes’ residents, nursing staff, family and caregivers, administrators, and facility owners, as well as community and clergy members. Further, public health officials acknowledged their experiences and difficulties that manifested as sleeplessness, worry, dread, and feelings of guilt through the summer of 2021. This is evidence that those who care for older persons were profoundly affected when the needs and rights of residents were not upheld (Banerjee & Rai, 2020; Beogo, et al., 2022).

We considered Maslow’s Hierarchy of Needs (Hale et al., 2019; Maslow, 1970; Ryan et al., 2020; Shih et al., 2019) as a guiding framework for understanding the needs of older persons in this unique situation. Through a psychological approach to human science, Maslow established the five needs in order of importance to full development. First, physiological needs like food, shelter, and water must be available, accessible, and met. Then, the subsequent needs follow in order: safety, love and belongingness, self-esteem, and self-actualization (Maslow & Frager, 1987). According to the findings of this equity-centered community project, as SI increased over time during the coronavirus disease 2019 pandemic, each need on the hierarchy became more difficult to navigate. Coronavirus disease 2019 restrictions, from not allowing families to visit to closing dining halls and mandates to stay in rooms, affected each need. For example, physiological needs (e.g., shelter and food) were threatened when nursing homes enacted policies that would not allow residents to return if they left the facility to visit friends or family. Safety was threatened by the existence or threat of the virus. Love and belongingness through regular visitation were de-emphasized to protect older adults from becoming infected. Self-esteem, likely obtained from being with others and asserting oneself in some capacity, was excluded in favor of safety. Finally, self-actualization was not prioritized. Ultimately, the inattention to human needs as identified by Maslow affected older adults in ways that touched the outward experiences of quotidian activities and highlighted that the core essence of life, especially in older persons, is not only maintaining physical life but nurturing and nourishing psychosocial life.

In addition, we considered how the biopsychosocial aspects of living in a nursing home are moderated by the social relationships residents have with direct caregivers, other care providers, clergy, family members, and other residents. While the social restrictions applied to residents during the pandemic were harsh, they conversely fostered the use of technology to bridge gaps in telemedicine and the frequency of family virtual visitation (Saad et al., 2022). Unfortunately, the lack of secure and stable internet connections increased access disparities between urban and rural nursing homes (Singh et al., 2020). Further, staffing issues, especially high turnover rates, continue to plague the industry and often result in lower levels of person-centered care and poor relational coordination (Gittell et al., 2008; House et al., 2021).

Additionally, federal and state policies can leverage increased cellular tower and satellite installations for better coverage in rural areas, including by subsidizing cellular and internet rates for nursing homes, direct care staff, and residents, and can provide funding for additional and dedicated frontline staff with the necessary training to leverage new technologies to combat social isolation. State regulators could add and enforce requirements related to the provision of access and use of technology to address SI, focusing specifically on dedicated staffing and access logs to demonstrate equity and effort.

The policy implications are clear: increase older adults’ access to secure, stable internet services; address staffing issues in the nursing home workforce; and improve team communication in nursing homes.

Policymakers also must recognize the importance of seeking solutions from those most directly affected—namely, older persons in nursing homes—and balancing their preferences relative to those of nursing home staff and administrators and other stakeholders, as well as state and local public health officials. Perhaps a first step would be to establishing a baseline rate of SI to refer to in such times of crisis. Additionally, nursing homes could incorporate just-in-time trainings for emerging medical threats, team communication strategies, policies to measure resident and employee satisfaction with organizational communication, and employee preparedness to care for residents during such trying times (Colon-Emeric et al., 2013; Howe, 2014).

Acknowledgments

We thank Debera Yellseagle, members of the Advisory Committee, and community members. Additionally, we profoundly thank Dr. Rae Walker for guidance in the use of the Equity Centered Community Design.

Funding

This study was funded by the Oklahoma Shared Clinical and Translational Resource Center (U54GM104938, funded by National Institute of General Medical Services-National Institutes of Health).

Conflict of Interest

None declared.

References