COVID-19 Pandemic: The Lived Experiences of Older Adults in Aged Care Homes

Abstract

The COVID-19 pandemic has caused untold fear and suffering for older adults across the world. According to the World Health Organization, older adults in aged care homes are at a higher risk of the infection living in an enclosed environment with others. This article adopts a qualitative approach using Colaizzi’s phenomenological method to explore the lived experiences of older adults during COVID-19. Between December 2019 and June 2020, 10 in-depth, semi-structured interviews were conducted with participants aged 60 years and above in two aged care homes. The lived tension that has penetrated all participants’ stories in five themes of the meanings described as ‘disconnected in a shrinking world’ filled with uncertainties. COVID-19 has brought unprecedented challenges and disproportionate threat onto older adults’ lives, relationships and well-being. The overarching message was that older adults believe that ‘this too shall pass’ and regain their freedom that was lost during the pandemic.

I. Introduction

Malaysia will be an ageing nation by the year 2030 as the present older adults are living longer than their predecessors (Department of Statistics Malaysia, 2020). In Malaysia, the National Policy for Older Persons (KPWKM, 2011) defines an older adult as an individual aged 60 years or above (Hasmuk et al., 2020). With this pandemic significantly affecting older adults globally, the novel coronavirus (COVID-19) has caused untold fear and suffering from a ripple effect on every aspect of life (Lai et al., 2020; Nicola et al., 2020). On 3 May 2020, it was revealed that 99 out of 105 COVID-19 deaths reported in Malaysia, the highest COVID-19 deaths were from the age group of 61–70 years with 32 cases (32%), followed by the age group of 71–80 years with 19 cases (19.2%) (Abdullah, 2020b). According to the Ministry of Health (MOH), as of 18 May 2020, the number of confirmed positive cases aged 60 years and older consists of 961 cases (13.8%) out of the total number of 6,941 cases (Abdullah, 2020a). About 744 cases (10.8%) of all confirmed positive COVID-19 cases involved those with underlying multimorbidity, including diabetes, heart disease, liver disease, diabetes, hypertension, kidney disease and other chronic diseases (Abdullah, 2020a).

The risk of COVID-19 infection was significantly higher for older adults with underlying multimorbidity who live in long-term care facilities, aged care homes, nursing homes and similar facilities (Lloyd-Sherlock et al., 2020; Wang et al., 2020). Given their increased vulnerability to this virus, previous studies have established that aged care homes with older adults are most vulnerable to the impact of COVID-19 pandemic (Garnier-Crussard et al., 2020; Roland & Markus, 2020; Wang et al., 2020). Unfortunately, aged care homes can act as an incubator of infection (Armitage & Nellums, 2020; Berger et al., 2020). Many cases of older adults being infected were caused by uninformed visitors which has imposed an increased burden onto the aged care and healthcare facilities (The Interim Recommendation Development Group, 2020). By the end of May 2020, MOH adopted a mass-testing strategy for all registered and unregistered aged care homes. On 4 June 2020, after screening a total of 14,285 individuals from 385 aged care homes, there were 26 confirmed positive COVID-19 cases (Abdullah, 2020b).

As an effort to break the chain of COVID-19, the Movement Control Order (MCO) was enforced on 18 March 2020 (Shah et al., 2020). Additional challenges may surface as the restrictions on visitors have required additional staffing to aid the movement of visitors coming in and out of the homes (Karim & Haque, 2020). Older adults were not allowed to have face-to-face contact with their family members out of fear that they may comprise of at-risk individuals (Shah et al., 2020). Long-term social distancing during the pandemic with decreased contact with loved ones could cause older adults to experience unnecessary stress, breakdown in relationships and uncertainty about the future (Lai et al., 2016). Aged care homes also faced significant financial challenges due to the COVID-19 pandemic (Hasmuk et al., 2020; Povera, 2020; Shah et al., 2020). On 27 March 2020, the Malaysian government introduced the Prihatin Rakyat Economic Stimulus Package (PRIHATIN) with RM 25 million allocated to provide assistance for aged care homes, including cash disbursement, food supply and healthcare items, as well as a RM 250 one-off payment for government pensioners (Ministry of Finance Malaysia, 2020; Povera, 2020).

Previous studies have stated that current aged care homes lack basic personal protective equipment (PPE) and have difficulty observing physical distancing within their confined spaces (Hasmuk et al., 2020; Wang et al., 2020). Based on World Health Organization (WHO)’s recommendations, caregivers that provide direct and indirect care to older adults should wear masks, gloves, goggles, perform hand hygiene and, when necessary, put on gowns if they are caring for people with symptoms suggestive of COVID-19 (WHO, 2020a). The results of these studies indicate that it is important to remember that people who are currently in their 80s and 90s are those who experienced the Second World War and the subsequent ‘economic boom’. In the past, they learned how to cope with difficult situations and developed ‘post-traumatic growth’, and now they are demonstrating it with high civic sense (Petretto & Pili, 2020).

The COVID-19 pandemic has brought unprecedented challenges and a disproportionate threat to humanity, especially to the older adults’ lives, relationships and well-being. Given the spread of the new coronavirus and its impacts on human health, no one knows how long this pandemic will last and its long-term toll on older adults living in a confined environment (Adhikari et al., 2020). To date, the lack of information available within the literature necessitated the importance to negate the effects of the COVID-19 pandemic which may impact quite negatively on aged care residents and the higher mortality rates for older adults (United Nations, 2020).

Therefore, the primary aim of this phenomenological study was to explore the lived experiences of older adults in an aged care home during the COVID-19 pandemic, especially their perspective on how it has impacted their daily routine, relationships and overall well-being. Section II describes the method on study design, setting and sample, data collection and data analysis; Section III describes results of the emerging themes; Section IV analyses discussion on the dimensions on how meaning was constructed. Section V concludes the article by examining the potential impact of these themes on care provision, policy and research in aged care homes. Apart from being a future study on upcoming post-pandemic aged care homes, this study aims to provide insights for caregivers on future needs to prepare for a post-pandemic plan and hopefully pave the way for changes in governmental policies beyond the minimum requirements enforced by the law.

II. Methods

Study Design

This qualitative research is driven by an interpretivist paradigm. The Colaizzi’s phenomenological approach was the chosen method of inquiry to understand the lived experiences of older adults in aged care homes using thematic content analysis to identify and interpret data (Colaizzi, 1978). This approach was driven by the philosophical phenomenology that is focused on illuminating the essence of the studied phenomenon (Moustakas, 1994). The author employed this phenomenological attitude throughout the duration of the study with documented ongoing reflection in a reflective research journal that also contained notes taken during data collection. This reflective process enabled the author to bracket any preconceived ideas and prevent bias because the study is concerned with the nature of reality (Colaizzi, 1978; Moustakas, 1994).

Setting and Sample

The two aged care homes are private, not-for-profit homes primarily operated by caregivers in the suburban city of Subang Jaya. The author selected two aged care homes with comparable care service qualities, daily living activities, demographic distribution, building typology and environmental features: one with 40 beds and the other with 25 beds. Both aged care homes were selected because they were accessible and complied to regulations with travel within a 10 km radius from the author’s home. It was in accordance with the allowed perimeter of MCO under The Prevention and Control of Infectious Diseases Regulations 2020 (Attorney General’s Chambers of Malaysia, 2020) and subsection 11(2) of the Prevention and Control of Infectious Diseases Act 1988 (Act 342). These acts were part of the necessary measures purposed to prevent the spread of COVID-19, according to The Commissioner of Law Revision Malaysia (2006).

Most older adults in the study had multimorbidity, including dementia, diabetes, rheumatoid arthritis and other illnesses whereby they would require assistance from caregivers to carry out daily activities. Although both aged care homes consist of rooms of different sizes that have between one and eight beds, there were no allocated space purposed for infectious diseases. The participants were purposively sampled with 10 older adults comprised of five women and five men, aged 60 years and above (WHO, 2020b) that have lived in the aged care home for a duration between 6 and 30 months. The inclusion criteria were (a) older adults aged 60 years and above; (b) possess the ability to express him/herself verbally; (c) no cognitive impairment; and (d) willing to participate voluntarily in this study. Regarding the functional abilities of the participants, all participants were able to eat meals without assistance. However, several participants required assistance to perform several activities including toileting, bathing, getting in and out of clothing, daily exercises, moving around the home, grooming and help with personal hygiene.

Data Collection

Subsequently, semi-structured, in-depth, one-on-one interviews with 10 participants were conducted with open-ended questions. The primary question was, ‘Could you please tell me more about your life during COVID-19?’ Other questions included, ‘How do you feel about the pandemic as an older adult in aged care?’ and ‘Please describe the difference between life before and after COVID-19 occurred’. Furthermore, probing questions such as ‘can you elaborate’, ‘what do you mean exactly’, or ‘give me an example’ were asked to encourage participants to share more in-depth information.

The data collection process was divided into three stages: (a) a semi-structured interview with participants, (b) follow-up interview and (c) presenting a summary of the findings to the same participants for validation to ensure the vigour and trustworthiness of the study. All participants were interviewed two times, and the interviews lasted between 25 and 60 minutes. Colaizzi’s method requires the author to conduct data collection and data analysis simultaneously. The semi-structured interviews were recorded and stored in secured digital files that consists of both audio recording and transcribed verbatim. Semi-structured interviews were conducted until data saturation was achieved with no new themes emerging.

Data Analysis

The data analysis process was conducted using Colaizzi’s (1978) phenomenological method in seven different stages: (a) read and re-read all the transcribed interviews several times to make sense of them; (b) significant descriptions are extracted from the transcribed interviews of identified phrases or sentences that directly pertained to the experience of aged care home life during COVID-19; (c) the meaning of each significant statement were enumerated; (d) repeat the first three steps for each description, and create themes based of formulated meanings of the descriptions. Subsequently, the interpretations were conceptually validated by two scholars with vast experience in qualitative research. To increase the reliability of the study, suggestions from aged care home managers and the scholars were obtained; (e) an exhaustive description were integrated from the results; (f) the exhaustive description were summarized to formulate the fundamental structure of the phenomenon; and (g) to ensure the credibility of the data collected, the author validated the data through discussions with experts and went back to the participants to validate the findings. The phenomenological investigations are purposed to deepen the knowledge on the lived experiences with thoughtfulness and tact within an aged care home during a pandemic.

III. Results

Five primary themes are identified within and across the aged care homes during the COVID-19 pandemic, each with overlapping subthemes. Throughout the duration of the study in the two aged care homes, there were no suspected or confirmed cases of COVID-19. Through in-depth interviews, it allowed participants to express their understandings, motivations and meanings. The intention is to present in-depth understandings on the lived experiences of participants, or the meanings, rather than quantifying their responses. To denote a small number of participants of less than five participants, the descriptor ‘some’ was used, and direct quotes from participants were italicized. In this section, together the essence and the constituents provided the detailed description of what it means to be an older adult living in an aged care home during the COVID-19 pandemic.

Living with Multimorbidity and Functional Limitations

Older adults in aged care homes have an even higher risk of getting infected with COVID-19. Due to old age, they are no longer able to perform daily activities. With the prevalence of COVID-19, participants talked about gloomy feelings of not being to do anything about their situation due to their multimorbidity; it became gradually more difficult. Some participants first described how the aged care home lacked capacity and how at most times, they were unable to distance themselves from other residents and caregivers socially. It was found to be a challenging and frightening time for participants with multimorbidity who are battling both physical and social losses. Apart from the threat of the COVID-19 pandemic, participants viewed their body as something limiting, and often considered themselves as being ‘handicapped’ due to their deteriorating health conditions. When participants were asked to describe their main concern during the MCO, some participants expressed their fears on addressing the ongoing health needs that may require them to seek medical treatment or attend follow-up treatment. These arrangements, however, are now at risk of being further disrupted by measures to limit the spread of COVID-19. Participants reported feeling anxious as they were concerned about their safety and dreaded to leave the aged care home to the hospital, as one participant explained so eloquently:

I can’t risk having to leave the home to seek treatment during COVID-19. […] I think about going to the hospital also feel scared. (Participant 1)

While every older adult’s health conditions may vary, participants felt fragile. Explaining not only the reasons for their state of mind, some also described their deteriorating functions as a dreadful condition to be in, in the event of complications that may arise as someone with multimorbidity. With the aggressive spread of COVID-19, participants with functional limitations weighed in on how it has affected their desire to perform daily activities in a group of people that were considered vulnerable. Participants with other health concerns such as respiratory difficulties, rheumatoid arthritis or loss of muscle preferred to avoid interacting with others that may lead to loneliness, frustration or social isolation. A participant who expressed her frustration in the following excerpt:

At my age, you have very little do so. With the imposed Movement Control Order, we can’t even leave the home or walk to the park. So, I try to keep busy by reading books, rest in bed or to help out chores to kill time. It can get lonely since I do not own a mobile phone. I sometimes try to exercise in whatever open space I can find since this home compound is a corner lot. […] I was more concerned about being hounded by other residents or being sent to the hospital for treatment. (Participant 2)

With their vulnerability to infection, some participants have spent their days without doing anything, even talking to others, as an effort of keeping up with the requirements of ‘social distancing’. They begin to regard life as suffering.

Multidimensional Feelings of Fear and Uncertainty

All participants expressed feeling a sense of fear and uncertainty in their stories. Some had difficulty understanding the exact magnitude of the COVID-19 pandemic because they have spent most of their time away from the outside world. In their minds, participants regarded the spate of deaths in aged care homes around the world, as a place no different from their own; perceived as a place filled with older adults awaiting death. Older adults are vulnerable at the onset of the COVID-19 pandemic, even within the boundaries of the aged care home. It has limited the participants’ social lives which resulted in additional stress onto their constant worrying about their deteriorating health conditions, as described below:

The living environment here is good but I don’t feel safe. A few months back I felt safe, but now, hard to say. The rules are flexible too, as long as we don’t utter bad words and create a negative atmosphere, we are free to move around on our own. What I worry about now is the disease, I watch the news, they said that it is harder for old people like us to survive the disease. (Participant 10)

Depending on their digital savviness, participants mentioned their fear of not knowing what to expect from the pandemic. Some participants explicitly regretted their decision of living in aged care home instead of with being with their families. Being isolated during the lockdown caused them to feel side-lined when their request to gain access for information to stay informed about the COVID-19 pandemic was declined. Some gradually withdrew into themselves when they feel challenged with the barriers of access to information. Participants often raised their concerns about not being able to remember or understand the information on COVID-19 self-preventive measures, which could potentially expose them to a higher chance of infection. During the MCO, as a method to limit the further spread of COVID-19, participants could only depend on in-person caregivers as the main source of information and support, as explained by Participant 5:

I am on a wheelchair, so I figured it is only natural to feel disturbed by the news because I am not in the position to do most things on my own. I will always need a helping hand. I used to stay alone last time before the incident. Due to my leg’s immobility, I needed someone to carry me about and the male caretaker here is strong enough to do it. My life is pretty much in the hands of my caregivers. (Participant 5)

As a whole, participants in this sample preferred to stay informed about the pandemic. The element of fear was reported as participants were aware that older adults with multimorbidity, like themselves, are more vulnerable and may experience more severe complications from COVID-19.

Disconnection from Outside World

More and more profound the changes to the shifting aspects of aged care homes ensued, some participants have experienced severe disruption from their pre-existing needs. One participant expressed his feelings with ‘my time is up’. Participants seemed to emphasize the issues that emerged due to COVID-19; caregivers struggle to provide care for all residents. Nothing was able to make up for the shortage of external support to assist caregivers, mainly due to the no visitor policy on family members, which resulted in participants scrambling to adapt to the sudden disconnection. This change affected participants negatively because family members played a role as secondary caregivers. With the stricter directives imposed, they felt upset because they were isolated from their loved ones and were unable to spend time with their family. In the following excerpt, Participant 8 expressed her longing for her daughter:

I moved in because I am alone in the house. […] I miss her a lot, although my eyes cannot see anymore, I want her to help me sort of my clothing and medicine. I wonder when will this pandemic be over? (Participant 8)

Several participants also talked about the aged care homes struggle to cope with the lack of human resources because there were caregivers who opted to quit in fear of getting infected by COVID-19. It resulted in insufficient care attention for most participants. Some participants nearly lost their nerve and threw tantrums because they were not able to get sufficient support, attention and encouragement from caregivers who were short-handed. The effects of the MCO period left participants who were used to frequent visitations by their loved ones, to feel lonely and helpless. In several cases, participants have nothing to look forward to; therefore, their ongoing expectations and uncertainties about the future could lead to detrimental long-term emotional effects. A 63-year-old man reported:

I am suffering. I am unhappy. I don’t want to live that long. What is the point? I am surrounded by a group of old people, the oldest in her nineties, she is at least 30 years older than I am. The thought of having to spend another 30 years here was already bad enough, and now with COVID-19, no one knows what will happen. Take it from a ‘young’ older adult who is stuck here because I am half-paralyzed, I have absolutely nothing to look forward to. (Participant 4)

However, at the same time, many felt trapped and detached from the outside world because they were not allowed to leave the aged care home. Participants expressed their disappointment because they were used to having volunteers around that would conduct enjoyable activities and spend time with them.

I am on a wheelchair. I enjoy reading the newspaper, but we don’t have on a regular basis anymore since the virus happened. No one to buy us newspapers, they are usually sponsored by those who visit, there are regular volunteers who know which paper we like. There is no one to bring me out anymore. The caregiver had to be careful with receiving external goods for our safety, that I can understand but I really wish to have people from the outside here. They make me feel normal. Now I am just stuck. (Participant 7)

Despite being in the presence of many people, some felt a sense of detachment from the world when their daily experiences are incompatible with their expectations. As a result of the MCO, their repetitive and monotonous daily activities caused them to feel bored, and perceived their routine as misery:

To put it simply, passing time became difficult. It’s like I’m useless. There is no sense of satisfaction and that was somewhat missing. (Participant 6)

Confined in ‘Shrinking Spaces’

As connections to the outside world stopped, participants’ movements, activities, spaces and interactions were significantly reduced. The experience of being confined within the aged care environment clearly emerged in the interview with several participants. Participants felt restricted and suffocated due to the COVID-19 pandemic. Most participants mentioned viewing themselves as ordinary older adults who are trapped in a crowded environment. In most stories, an intense dissatisfaction towards overcrowding in shared common areas was described as a ‘shrinking space’. In most cases, physical distancing was reported to be almost unachievable in aged care homes. This was due to lack of daily activities during COVID-19, which led residents to spend a majority of their time in the communal living area watching television as their only source of entertainment. For most, living within a confined environment and the associated health limitations intensified the unpleasant negative feelings and emotions:

Everyone is awake and restless. How to take a nap when everyone is up? The house is noisy during the day and night because everyone has been affected and worried about COVID-19. When I say worry, at our age, we are also worried about our family. The only way to cope is to chitchat with others and stay informed. No other source of entertainment anyway. Those volunteers stopped coming, so no fun activities. Now it is just us. For the ones who cannot sleep, just watch the television in the living area, chat, and continue on with our usual routine. (Participant 10)

More than half the participants were pleased with the rearrangement of spaces and objects within the aged care home. They viewed it as a reasonable effort by caregivers to enhance movement and promote activity during COVID-19, as a safety measure to prevent unwanted fall accidents. Notwithstanding their functional limitations, the perception of environmental barriers as negative features remained unchanged. To all participants, these negative spaces were regarded as ‘impossible to fix’, such as insufficient manoeuvring space, high curbs, no handrails, no ramps and inadequate shelter from the weather which limited the amount of outdoor space when it rains. As time passed, participants describe a progressively shrinking world due to restricted movement, particularly for older adults who require assistance to get in and out of the wheelchair.

For someone on a wheelchair like me, during this COVID-19, the home felt almost much smaller. Every corner of the house is filled with people, and as someone considerate, I try not to disturb anyone’s peace. Some may have bad habits of leaving objects on the ground. When I see it from a far, that alone stops me from getting out of bed. To move around the house, I would usually require getting someone to help me onto the wheelchair. […] As you get older, the house will only seem to get larger if you are able to walk. However, if you are wheelchair dependent, the ‘roads’ for me to move around felt more like a small alley. (Participant 9)

With their reduced mobility and capacity to move, participants were unable to find space to be alone and disconnect with others. Participants expressed their frustration to get sufficient rest as they suffered from sleep disturbance which caused daytime sleepiness. It has reportedly worsened due to space limitation with the aged care home filled to full capacity with older adults. Participants often feel distressed and overwhelmed by the level of noise at every hour of the day. Some participant felt powerless because they have no control over most of their monotonous and repetitive daily routine:

I don’t take afternoon naps, only at night. […] No one sleeps well in an aged care home, especially during this crazy times. Everyone is constantly worried when they hear someone coughing, as that is one of the main symptoms of COVID-19. (Participant 7)

As we get older, it gets harder to sleep long. I happen to be sensitive to sound, so even the slightest noise would wake me up. Recently it became worse. Everyone is so energized because with the lack of activities, some took naps during the day and found it hard to sleep at night. (Participant 10)

Overwhelmed Residents and Caregivers

Most older adults mentioned feelings of being overwhelmed. There could also be an increased risk that age could represent a negative factor when the critical phase of the pandemic puts high pressure on the aged care home system, and the availability of caregivers is not enough to cope with all the needs. In most stories, this was due to the disrupted balance in their ‘new normal’. Some participants described how the ‘new normal’ had shifted the balance between their quality of life in aged care and their expected support to maintain a good quality of life. There was an apparent lack of liveliness or enthusiasm left from both residents and caregivers. Several participants reported being aware of the caregivers’ tiredness but were not able to relieve their stress or workload. They too admitted being caught in a position where their worries about their family members became their primary concern and were unable to support anyone else during the COVID-19 pandemic. All participants concurred that there is a need for more caregivers because the lack of human resources has overstrained existing caregivers.

If I were to describe our current situation now with the COVID-19 getting serious, our current home can be very stiff. You cannot move around. Very limited. I pity the caregivers; they cannot leave the home to protect our well-being. They don’t want to take any unnecessary risk of getting infected, so we are grateful for that. Not easy because they have their own loved ones to worry about too. Everyone is affected. It is the compassion of the heart to do this job well. They are willing to help the old people that’s why the environment is so good. Now we have no visitors allowed. So, there are no donations of food supplies and I think the caregivers are also trying to be extra careful. The only person who leaves the home to secure supplies is the manager. (Participant 5)

Over a long duration, the growing tension evoked feelings of being submerged. Most participants slowly became worried and concerned about the well-being of their caregivers. Even though they were in the position of receiving care, participants acknowledged the struggles of caregivers’ work schedules, fearing that it might jeopardize the health and safety of the residents if they caregiver were to become ill. A few participants realized that there was a limited amount of basic PPE such as eye protection, gloves, face shields, respirators and surgical masks. Although caregivers have explained that it was not necessary to wear them at home, it did not resolve their concerns. Most participants felt anxious and helpless about not having sufficient supplies to be used in case of an outbreak. For participants who had the intention to take precautionary steps, they were unable to secure supplies on their own because of the no visitor policy. Many participants felt that the feeling of fear was something unavoidable and preferred to focus on making short term goals such as being able to meet up with their families, in order to survive this unprecedented COVID-19 pandemic:

All my life I’ve been able to move around and suddenly I was just stuck. I can’t move and I have to rely on people. I am worried and afraid. I see the neighbours leaving their houses with mask, eye goggles and some even wore gloves just to leave their homes. I wonder what will happen to me if one of us get infected? The caregivers themselves also have limited supplies of those items, so would there be enough resources for us? You would feel very down at the start, but I tried to stay positive. I told myself that I am only going through a transition, after a few more months, I hope to be able to meet my family. (Participant 5)

Other participants spoke profoundly of their dependence on their caregivers with the absence of additional support from family members and volunteers. In most cases, due to the absence of external caregivers, participants gradually became more attached and overly dependent on their caregivers. Being overly dependent was described with both frustration and disappointment, expressed in a manner that reflected a sense of contradiction within themselves. Participants wish to be independent and talked emotionally about allowing caregivers to take over the roles of their loved ones. With the absence of their loved ones, there seemed to be only one option left for them to relieve the strain and gain reassurance during stressful times. Among the components of coping with the difficulties during COVID-19, one of the major challenges was being disconnected from loved ones and all the worrying that follows:

In such challenging times, I can only rely on caregivers. If they go down, who is going to take care of me? There is no guarantee that COVID-19 will be gone forever and at my age, I don’t know technology like young people. I was only nine years old when World War Two ended, never thought that this day would come. (Participant 3)

Less explicit but present in these stories were the feelings of powerlessness. Most participants felt even more powerless and expressed their desire to reconnect with society, especially their families. Being in an aged care home during COVID-19 was described as a form of confinement or ‘late-life punishment’ by some participants. The element of fear and distrust continue to exist because they felt that they were no longer in the position to protect themselves. These adverse effects as a consequence of the COVID-19 pandemic will undoubtedly be intensified as older adults become more dependent on others for support especially for those who are incapable of practising the levels of personal hygiene recommended to prevent COVID-19 infection (Gardner et al., 2020; Ong et al., 2016). According to previous studies, the increased dependency of older adults on others is one of the strongest predictors of abuse in aged care homes (Gardner et al., 2020; Han & Mosqueda, 2020). In the following excerpt, Participant 5 shared his heightened fear of abuse:

…abuse is often overlooked because it usually happens when no one is watching. For example, when the caregiver gets frustrated by my weight and start raising their voices when they help me clean up or take baths. I know I am heavy. I have gained lots of weight after I lost complete control over the lower half of my body. You complain and you get into trouble. You might even be at risk of getting kicked out. I have nowhere else to go because most of my family members are down south in Johor. Due to this pandemic, they are unable to send me money or food, help out with caregiving or day to day activities. (Participant 5)

The lack of family visitation could also increase their vulnerability to abuse and neglect which can be in the form of emotional, physical, financial, neglect or a combination of these (Gardner et al., 2020). The unbuffered time together in lockdown could lead to circumstances leading to higher potentials of abuse and older adults may not be able to seek help (Han & Mosqueda, 2020; Nicola et al., 2020). With the pandemic restricting visitors, older adults are also susceptible to potential psychological stress worrying about financial hardships as some participants are dependent on their family for financial support and to monitor the quality of care (Makaroun et al., 2020).

IV. Discussion

Disconnected in a Shrinking World

Using Colaizzi’s phenomenological method, the purpose of this study was to explore the lived experiences of 10 participants from two aged care homes during COVID-19. The essential meaning of the studied phenomenon is understood as the lived tension that has penetrated all participants’ stories: the emerging contrasting perspectives was different to what was experienced before the COVID-19 pandemic. While provisions were made to ensure that COVID-19 preventive measures were implemented throughout the interview, fewer older adults were willing to participate in the interview. To add on to literature on older adults in aged care homes, empirical research into the lived experiences of this novel COVID-10 pandemic is very limited. The results of this study add onto the literature by previous studies that have, to date, comprehensively studied the societal issues related to COVID-19 (Alradhawi et al., 2020; Applegate & Ouslander, 2020; Armitage & Nellums, 2020; D’Adamo et al., 2020; Petretto & Pili, 2020; Wang et al., 2020).

This study probably provides the first in-depth findings on the lived experiences of older adults in aged care during COVID-19 within the studied context. It is also worth noting several contributions of this study: (a) it provides a preliminary characterization of the studied population; (b) it depicts the underlying assumptions focused on its rational construction; (c) it illustrates how the will to survive COVID-19 extends beyond an individual’s experiences; and (4) it questions the implications of COVID-19 on aged care homes.

First, through phenomenological analysis, dealing with uncertainty amid the COVID-19 pandemic has been recognized as part of the ubiquitous worldview. The results reveal that older adults are driven and characterized by their uncertainty on what lies ahead, fear of death, fear of getting infected, and how they react to the repercussions of these feelings of uncertainty that became gradually hard to ignore. The older adults are constantly stressed about the consequences of being infected COVID-19; they were worried about themselves, family members, caregivers as well as other residents. The older adults also slowly developed signs of fatigue, stress and paranoia throughout the lockdown period in the aged care homes. For example, several participants with multimorbidity admitted being overwhelmed with fear by the thought of receiving medical treatment or routine check-ups at the hospital.

In the earlier developmental stage of the outbreak, emerging data have indicated that older adults have a higher risk of contracting COVID-19 (Applegate & Ouslander, 2020; Garnier-Crussard et al., 2020; Jindai et al., 2016; Leung, 2020). The results reveal that even for older adults with multimorbidity in old age, their desire to survive prevailed, as reflected through their actions by socially disconnecting themselves out of fear of getting infected. Being old does not mean that they were ready to give up on life. Results revealed that even for those inundated by multimorbidity together with their lifelong fear of death, older adults are generally fearful of COVID-19. Some participants developed a fear of communicating with others; there are no preventive measure for residents unless they have been exposed to high-risk areas. Although studies have recommended optimizing the use of face mask for vulnerable populations such as older adults (Adhikari et al., 2020; Feng et al., 2020), participants reported a shortage of face mask supplies and difficulty in breathing when worn for a prolonged period of time. The consequences of being infected have the potential to be deadly for older adults who are, by definition, vulnerable towards COVID-19 (Garnier-Crussard et al., 2020). Therefore, it seems essential to limit the risk of spreading the virus in facilities caring for older adults at all costs.

While a sense of safety and security are among the most important according to participants; there is also a need to implement appropriate safety measures for caregivers or visitors. The results clearly show the uncertainty, frustration and emotional impact of the participants’ perspective caused by their fear of COVID-19. Other studies emphasized on the importance of addressing the older adults’ demands; instead of dismissing them as private emotions (van Wijngaarden et al., 2015) and complex responsibilities associated with the caregiver’s role to provide accurate, informative updates on COVID-19 (Lloyd-Sherlock et al., 2020). Participants rely on caregivers as the primary source of information about COVID-19 to provide them with regular updates and information about the pandemic. Most older adults may have limited access to information on COVID-19 and are less familiar with digital technologies, mainly due to a ‘digital divide’ (Lloyd-Sherlock et al., 2020; Petretto & Pili, 2020). As society contemplates the ramifications of this rapidly moving global pandemic, it is clear the need for care support services in aged care homes has never been greater and may continue to increase (Duguay et al., 2014; Jackson et al., 2020; Leung, 2020).

During this COVID-19 crisis, the caregivers who provided care for the participants were mainly by caregivers. This experience may be worse for older adults, especially for those who are fully dependent on care support. The reduction of social activities, those who rely solely on the support of caregivers or voluntary social services, could be placed at additional risk of feeling lonely, isolated, or secluded. Commensurate with other research findings (Armitage & Nellums, 2020; Morrow-Howell et al., 2020), many participants have chosen to take the initiative to socially disconnect by practising ‘social distancing’ measures, isolating themselves as an effort to help reduce transmission risk of the virus to minimize the spread to others. Although their intentions were mainly for self-care, social distancing remains a challenge with the close proximity and self-isolation has the potential to disproportionately affect older adults whose only social contact is out of the home, for instance, their spouse (Jackson et al., 2020; Wang et al., 2020). Such measures to protect themselves were taken to great length because they felt obligated to take the necessary precautionary steps as a promise made to their loved ones, to look after themselves. In this unparalleled COVID-19 pandemic, participants would have preferred to remain in their own homes with their loved ones. Participants described their aged care living environment as ‘confined in a crowded shrinking space’ and were concerned about the duration of the less-than-ideal living arrangement during COVID-19.

Due to the restrictions on visitation during the MCO period, caregivers were overwhelmed with the absence of visitors and volunteers to provide additional care. Such measures designed to negate the effects of COVID-19 may impact quite negatively on the aged care residents. During the critical phase of the pandemic, aged care homes had difficulty receiving donations such as food supplies, monetary donations and medical supplies (Armitage & Nellums, 2020). In aged care homes, visiting restrictions could potentially lead to anxiety concerning family members (Applegate & Ouslander, 2020; D’Adamo et al., 2020). Safety measures were taken by restricting all visitation and limiting the deployment of caregiving staff from other affiliated homes. Therefore, it is important to ensure that older adults are well-protected and provided with the necessary support throughout the different phases of the pandemic. Given the participants’ health condition, the aged care homes have tried to maintain normalcy in operations throughout the COVID-19 pandemic. While the theme of shrinking space is generally described in neutral terms, participants are feeling more affected than before COVID-19.

Participants expressed feeling trapped, confined and vulnerable; all of which are depicted with negative feelings because of the measures being enacted to protect them from COVID-19 (Makaroun et al., 2020). The experience described here indicates that older adults may view this COVID-19 pandemic as potentially ‘the end’. Even though the factors associated with the participants’ decision of moving into aged care are not discussed, the result demonstrates that the participants have thought a lot about future changes and shared similar sentiments with their families; being in the final stage of their life. Aged care home providers should be mindful that older adults are particularly vulnerable as a consequence of being socially isolated, financial hardship, complications in acquiring the needed care and supplies and anxiety about avoiding COVID-19 (Makaroun et al., 2020).

In line with previous studies, the result also revealed the effective engrained strategies to regulate caregivers’ collegial relationships with older adults that have helped with stress reduction for older adults (Jackson et al., 2020; Roland & Markus, 2020). To reduce the risk of exposure and cross infection, caregivers took additional precautionary measures before activities resume (Garnier-Crussard et al., 2020). The measures taken were according to recommendations by the WHO (2020), including avoiding crowded gatherings, minimizing physical contact, regular hand washing and routine checks to ensure that all residents are healthy. Additional measures were also taken to prevent a possible deterioration in mental well-being by providing opportunities for older adults to make video calls and exchanging photographs with their loved ones.

V. Conclusion

In conclusion, the COVID-19 pandemic has brought unprecedented challenges and a disproportionate threat to humanity, especially to the older adults with direct impact on their lives, relationships and well-being. Even though COVID-19 results in significant social changes, it has not changed the way the older adults’ perception of spending the rest of their lives in an aged care home. Some developed a fear of death when they were made aware of COVID-19 and had very little faith that they could overcome the COVID-19 pandemic.

Despite the ban on visits to aged care homes, relatives must be offered the chance to remain in contact with the older adults, while complying with protective measures. The results clearly show the need to promote the development of information programmes for helping older adults stay up to date with pandemic (McMichael et al., 2020). The necessary care and support must be provided by caregivers by being a reliable source of support, resources and protection to ensure the safety of the residents are well taken care of. Although this study has no direct implications for informing policymakers, it provides valuable insight in the lived ambivalences and ambiguities onto several issues; including the increase in uncertainty on what lies ahead, limited transition space, restricted movement, lack of personal space that was reduced during COVID-19 and not being allowed to leave the aged care home.

In the ‘new normal’, the necessary policies have to be continuously updated to protect the vulnerable communities until the end of the pandemic (Hall et al., 2020). There is no doubt that COVID-19 has an immense effect on the aged care sector, and the effect will be far-reaching, with some consequences not yet even discovered. Many had lived a long life and saw similar external representations of the COVID-19 pandemic, as one closely related to their triumphant survival of Second World War (Nicola et al., 2020). The overarching message was that older adults believed that ‘this too shall pass’ and regain their freedom that was lost during the pandemic. The study recommends future studies to continue exploring these experiences due to the evolving pandemic and develop new interventions to support the health and social impact on older adults in the event of another global pandemic.

Strength and Limitations of the Study

Since this is one of the first qualitative in-depth studies on the lived experiences of older adults in aged care homes during the COVID-19 pandemic, the author presumes that it can be considered a pioneering exploration that has provided valuable insights into an uncharted phenomenon. One of the identified strengths of this study is its exploration from a non-professional perspective within the context of an aged care home. The other strength of the study would be the author’s position to perform analysis of the data without any conflict of interest as she does not work in the field of aged care, political or government bodies. However, two limitations should also be considered. The first would be the risk of phenomenological reduction, where researcher biases are usually inevitable in qualitative research. The author implemented several strategies to improve credibility, transferability and validity such as bracketing to set aside any potential bias, member checking to gain participant’s validation of data and performed reflexivity throughout the study in a reflective research journal. The results of this qualitative study are not generalizable to other populations due to the small sample size.