Exploring what matters to residents of Australian aged care facilities with the Happy Life Index: comparison of qualitative responses between pre- and mid-Covid-19 pandemic time points

People living in residential aged care settings receive support with daily living tasks, social interactions and activities that maintain quality of life. External monitoring of resident satisfaction with facilities provides opportunity for service maintenance and feedback. This feedback process occurs in some Australian facilities using the Happy Life Index administered by CarePage Ltd. This tool includes two open questions asking what the best thing about the facility is, and what is an area for improvement. This study sought to compare the responses at two time points (before the Covid-19 lockdowns and restrictions and afterwards). We found that during times of restrictions, the staffing levels and visitor frequency was noticed by residents, with quality of food and staff mattering the most. More exploration is needed about the value of lifestyle activities and strategies for continuation of visitors during times of restrictions.

The rise in antibiotic-resistant bacterial infections in the community, an increasing national rate of known threats such as influenza and whooping cough, and the increasing emergence of new diseases, such as novel Middle East respiratory syndrome coronavirus (MERS-CoV) and avian influenza (H5N1 and H7N9), have made the control of communicable diseases a national priority [1]. Older persons are at an increased risk of communicable diseases, due to their reduced immune function, frailty, and the increased presence of comorbidities [2]. People living in residential aged care facilities (RACFs) are a particularly vulnerable group of older persons, secondary to the sustained proximity with other residents, and exposure to external visitors, including staff who may be working across multiple sites [3, 4]. RACFs are “special-purpose facilities which provides accommodation and other types of support, including assistance with day-to-day living, intensive forms of care, and assistance towards independent living, to frail and aged residents” [5]. They are also known as long-term care, care homes, nursing homes, and skilled nursing facilities. In Australia, RACFs can be government run or privately owned but all must be accredited by the Aged Care Standards and Accreditation Agency Ltd to receive funding from the Australian Government through residential aged care subsidies.

Restrictions of RACFs to visitors, limits on intra-facility movement, and limiting of staff to one site are some of the control mechanisms used for risk mitigation to prevent infectious disease transmission in an environment where residents live in proximity. Whilst the widespread use of lockdowns by governments during the current Covid-19 pandemic has been seen as controversial by some, they were used in RACFs prior to Covid-19 to help control other outbreaks, such as influenza [6].

On 18 March 2020, the Australian Federal government announced a raft of directives for RACFs including restrictions on visitor access, the need for social distancing, and the use of personal protective equipment to help stop the spread of Covid-19 [7]. This statement advised RACFs to limit visits from family and friends, particularly for residents with chronic illness. Following the implementation of these restrictions, the individual states instigated programs of lockdowns to help control the community spread of Covid-19. These lockdown practices in the aged care sector in Australia, and isolating RACFs early, may have contributed to the lower death rate among people living in RACFs in Australia compared to the UK [8], who were slower with instigating restrictions. Lockdowns or visitor restrictions in RACFs have become a widespread intervention globally to halt or slow the spread of Covid-19 among this vulnerable sector of the community [9].

With the rise of lockdowns and visitor restrictions in RACFs came concerns about the risk of social isolation and loneliness among residents with complex medical issues [10]. There is a growing body of research specific to the Covid-19 pandemic that has shown connections between decreased quality of life and community lockdowns [11]. This reduction in quality of life is perpetuated by social isolation and feelings of loneliness, possibly leading to negative physical and mental health among older adults [12, 13]. Specifically, the duration of isolation can be an important predictor of negative effects on mental health [14]. However, much of the existing research has occurred with people living in the community rather than living in RACFs and does not have pre-pandemic data (baseline) for comparison [15]. This creates a gap in understanding, particularly as people living in RACFs are not only subject to community lockdowns but may also experience restrictions on movement within their environment and have challenges with managing phones and technology [16]. As a result, they often depend on visitors and staff for their social interactions and are potentially at high risk of a decline in mental health during lockdowns and restrictions [17].

Prior to the pandemic, studies into the quality of life of residents in RACFs identified that sense of control and physical health were strongly related to the self-reported quality of life [18]. Other factors that have been shown to relate to resident reported quality of life include staff and resident relationships, autonomy and respect, sense of community, food, and drink, and activities [19]. In keeping with this literature, this study aimed to understand perceptions of what Australian older people living in RACFs like best about their facility and the suggested areas for improvement at two different time points: before the Covid-19 pandemic and during the Covid-19 pandemic (with the associated restrictions). This study will address the gap in knowledge about the perspectives of those living in RACFs and provide unique insight into the effects of the access restrictions put in place to mitigate risk and control the spread of Covid-19.

This research has analysed 8,512 open-text responses from 4,761 respondents in over 100 RACFs across five states in Australia. The data have arisen from two open-text questions in the Happy Life Index which was administered pre-Covid-19 (prior to 1st January 2020) and again mid-Covid-19 (after 1st April 2020) across most states and territories of Australia (except Australian Capital Territory, Northern Territory, and Tasmania). The two open questions in the survey asked the residents to say what they saw as the best thing about their RACF and suggestions for improvement. Overall analysis of the data set resulted in 12 categories with seven being observational and five being emotive. Not surprisingly, there were codes for dignity, privacy, and feeling safe which is consistent with qualitative research pre-Covid-19 [19, 25]. Homeliness, staff time, and flexible routines are also identified as highly valued by older people in pre-Covid-19 Australian research [26].

There were also codes related to mood, wellbeing, being offered choice, having a routine, and timely attention to needs. The most pertinent categories from comparison of the pre-Covid-19 and mid-Covid-19 data sets were food (general), staff (quality and number), environment (internal), social participation (friendliness), and feeling secure (safety). Food appears to gain increasing value during the mid-Covid-19 restrictions. Residents were more likely to report that improvements in food were required with a trend towards focus on food quality rather than quantity. This finding possibly reflects an increasing insular focus as exposure to the outside world reduces. Focussing on food service, in terms of variety and quality, ensuring adequate staffing and staff training/support and highlighting the safety precautions taken during the time of a pandemic may help maintain resident satisfaction.

Having needs met seems a logical finding as those within the RACFs will likely be focussed on whether they feel they have access to suitable medical and personal care that is delivered in a timely fashion. This finding is consistent with the growing body of literature related to ‘missed care’ which highlights issues with delays in responding to care needs such as answering bells or going to the toilet [27, 28]. These issues seem to stem from staff shortage and highly complex care needs that people living in RACFs often experience. The more specific finding in this research is the notion of having general choice about when personal care takes place, who will deliver that care and what their routine will look like. The participants identified that this choice diminished mid-Covid-19. This is likely due to staff shortages becoming exacerbated during the height of Covid-19 outbreaks [29].

Residents were more likely to report on the number of staff needing improvement mid-Covid-19 but reporting on the quality of staff remained positive. This finding aligns with a presumption that relationships with staff will hold greater value during the period of restrictions where numbers of visitors are reduced [25]. Communication with and spending time with residents becomes even more vital during visitor and activity restrictions when other ‘usual’ activities that boost mood are not occurring. Furthermore, communication with those who are unable to visit also becomes paramount [30, 31]. Lockdowns have been and will continue to be used as a risk management strategy to control the risk of cross infection in a community [6]. This study contributes to the growing evidence that residents of RACFs are vulnerable to the effects of restrictions on visitors and activities within RACF [32].

The study took a population-based approach, rather than exploring individual changes pre- and mid-Covid-19. One reason was the access to a set of unique data sets, collected anonymously from residents in RACFs across Australia, which precluded the ability to link the data to individuals. Even though data were collected Australia wide, there was no representation from one state and two territories. Consistent with the population-based approach, the large secondary data set across multiple RACFs in different states created an inability to fully describe the sample (i.e. age; functional status; time living in the RACF) and details of the context in which they lived, which could be considered a limitation. Even though there was evidence of continued restrictions during the time of mid-covid-19 data collection [23], it cannot be ascertained specifically when lockdowns occurred in RACFs, which is also a limitation. However, if the aged care sector is to recommend or implement widespread measures to minimise the effect of lockdowns and restrictions, then an understanding of the effects across the population is required.

Another limitation of the population-based approach was the inability to probe further with respondents about the meaning behind their free text responses. To manage this limitation there was rigour applied in interpretation and organisation of the data through having multiple data analysts that regularly conferred (researcher triangulation) and reflexively discussed how to assign codes [33]. Codes stayed very close to words used by respondents and the final decisions about organising the codes into categories were made through consensus. An inherent assumption is made that the frequency of responses equates to perceived importance which may not necessarily reflect the truth. Finally, it is acknowledged that information on the cognitive status of the individual resident was not collected. Whilst this is a limitation of the study there is no reason to assume that the cognitive profile across both cohorts would have been significantly different. Further in-depth qualitative work is recommended that explores specific effects of restrictions and lockdown on the codes identified in this study, and perceptions about their relative importance. More specifically, there is scope for further exploration of ways to promote feelings of connectedness, general wellbeing and contentment, and the value of lifestyle activities during times where there are restrictions in place.

People living in RACFs completed the Happy Life Index at time points prior to and during the covid-19 pandemic. Responses to two open questions on the survey were analysed and compared across the two time points. It was found that residents noticed changes in staffing levels and visitors during periods of restrictions. During these times, residents appreciated the quality of the staff attending to their needs and the quality of their food. The categories and codes provide useful insight into some parameters and priorities for quality of life for residents in RACFs that may influence further development of residential aged care specific quality of life measures [34]. Currently in Australia, the mandatory quality indicators for aged care have a strong clinical focus (i.e. medication management and pressure care) [35]. The plans to increase these indicators to have a greater focus on the quality of life and consumer experience are currently under consultation. The findings from this research using HLI may contribute to this discourse. Furthermore, given the reporting of pre- and mid-covid-19 findings, managers, and policymakers can also use this information to make decisions about the cost–benefit of restrictions and strategies for continued sustainment of resident satisfaction despite the presence of risk mitigation lockdowns and restrictions.