{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T13:22:52Z","timestamp":1789046572757,"version":"build-2803163510"},"reference-count":45,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T00:00:00Z","timestamp":1788998400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100015652","name":"Barts Charity","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100015652","id-type":"DOI","asserted-by":"crossref"}]},{"name":"NIHR Healthtech Research Centre for Community Healthcare"},{"name":"NIHR Applied Research Collaboration for the East Midlands"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Care homes in England experienced disproportionate harm during the COVID-19 pandemic, yet existing policy analyses offer limited explanation of the structural and positional vulnerabilities faced by care home managers. This conceptual paper applies systems-led setbacks and social positioning theory to examine how pandemic policies shaped care home management across macro, meso and micro contexts.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Qualitative research evidence relating to care home management during the pandemic was examined using a multi-level thematic analysis. Evidence was organised across six policy domains: hospital discharge, communication with families, personal protective equipment, end-of-life care, testing and surveillance, and vaccine roll-out. Recurring patterns were interpreted through the combined theoretical framework.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Five overarching themes were identified: liminal positioning, accountability displacement, rights erosion, information asymmetries and temporal misalignments. Across all six domains, managers were required to implement complex and frequently contradictory directives while operating with limited authority, incomplete information and insufficient institutional support. System-level decisions therefore interacted with managers\u2019 marginal organisational position, amplifying risk for both staff and residents.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Systems-led setbacks and social positioning theory provide greater explanatory depth than conventional policy analysis by showing how structural inequities and positional vulnerabilities compounded pandemic harms. Future preparedness frameworks should explicitly recognise the authority, information needs and institutional position of care home leaders, and involve them directly in policy design and implementation to reduce avoidable harm to people living and working in care homes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1916166","type":"journal-article","created":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T12:15:53Z","timestamp":1789042553000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Leading through crisis: care home managers\u2019 COVID-19 experiences examined through systems-led setbacks and social positioning theory"],"prefix":"10.3389","volume":"14","author":[{"given":"Fiona","family":"Marshall","sequence":"first","affiliation":[{"name":"School of Health Sciences, Queen\u2019s Medical Centre, University of Nottingham Medical School","place":["Nottingham, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam","family":"Gordon","sequence":"additional","affiliation":[{"name":"Academic Centre for Healthy Ageing, Barts Health NHS Trust, Whipps Cross Hospital","place":["London, United Kingdom"]},{"name":"Wolfson Institute of Population Health, Queen Mary University of London","place":["London, United Kingdom"]},{"name":"NIHR Healthtech Research Centre for Community Healthcare","place":["Oxford, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,10]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","DOI":"10.1093\/AGEING\/AFAD028","article-title":"More data can help us better understand COVID-19 outbreaks but nuanced and critical reflection is required","volume":"52","author":"Gordon","year":"2023","journal-title":"Age Ageing"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"1442","DOI":"10.1093\/AGEING\/AFAB101","article-title":"COVID-19 point-of-care testing in care homes: what are the lessons for policy and practice?","volume":"50","author":"Buckle","year":"2021","journal-title":"Age Ageing"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"811","DOI":"10.1007\/S41999-023-00804-Y","article-title":"\u2018Crack on\u2019: a qualitative study of care home managers experiences and responses to system-led setbacks during the crisis of the COVID-19 pandemic in England","volume":"14","author":"Marshall","year":"2023","journal-title":"Eur Geriatr Med"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/25741292.2020.1837466","article-title":"COVID-19: effective policymaking depends on trust in experts, politicians, and the public","volume":"4","author":"Cairney","year":"2021","journal-title":"Policy Des Pract"},{"key":"ref5","doi-asserted-by":"publisher","DOI":"10.1007\/S41999-026-01467-1","article-title":"Towards a typology of medical care in European long-term care homes","author":"Aasbrenn","year":"2026","journal-title":"Eur Geriatr Med"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"97","DOI":"10.1093\/AGEING\/AFT077","article-title":"Health status of UK care home residents: a cohort study","volume":"43","author":"Gordon","year":"2014","journal-title":"Age Ageing"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3310\/HSDR05290","article-title":"Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings","volume":"5","author":"Goodman","year":"2017","journal-title":"Health Soc Care Deliv Res"},{"key":"ref8","doi-asserted-by":"publisher","DOI":"10.14283\/JNHRS.2020.17","article-title":"The COVID-19 pandemic in UK care homes \u2013 revealing the cracks in the system","author":"Devi","year":"2020","journal-title":"J Nurs Home Res Sci"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"e017358","DOI":"10.1136\/BMJGH-2024-017358","article-title":"Health systems governance, shocks and resilience: a scoping review of key concepts and theories","volume":"10","author":"Belloni","year":"2025","journal-title":"BMJ Glob Health"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"705","DOI":"10.1007\/S41999-022-00637-1","article-title":"COVID-19 pandemic and mortality in nursing homes across USA and Europe up to October 2021","volume":"13","author":"Aalto","year":"2022","journal-title":"Eur Geriatr Med"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"afaa113","DOI":"10.1093\/AGEING\/AFAA113","article-title":"Commentary: COVID in care homes\u2014challenges and dilemmas in healthcare delivery","volume":"49","author":"Gordon","year":"2020","journal-title":"Age Ageing"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"100295","DOI":"10.1016\/J.LANEPE.2021.100295","article-title":"Mortality among care home residents in England during the first and second waves of the COVID-19 pandemic: an observational study of 4.3 million adults over the age of 65","volume":"14","author":"Schultze","year":"2022","journal-title":"Lancet Reg Health Eur"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"102","DOI":"10.1186\/S12877-021-02053-9","article-title":"Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study","volume":"21","author":"Marshall","year":"2021","journal-title":"BMC Geriatr"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"668","DOI":"10.1093\/AGEING\/AFAB015","article-title":"COVID-19 testing in English care homes and implications for staff and residents","volume":"50","author":"Micocci","year":"2021","journal-title":"Age Ageing"},{"key":"ref15","doi-asserted-by":"publisher","DOI":"10.1093\/AGEING\/AFAB229","article-title":"Are we allowed to visit now? Concerns and issues surrounding vaccination and infection risks in UK care homes during COVID-19","volume":"51","author":"Giebel","year":"2022","journal-title":"Age Ageing"},{"key":"ref16","volume-title":"Influenza Other Respir Viruses","author":"Emmerson","year":"2021"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1093\/AGEING\/AFAC097","article-title":"Mandatory vaccination against COVID-19 for health and social care workers caring for older people","volume":"51","author":"Gordon","year":"2022","journal-title":"Age Ageing"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"1290","DOI":"10.1016\/j.vaccine.2023.01.009","article-title":"COVID-19 vaccine hesitancy in care home staff: a survey of Liverpool care homes","volume":"41","author":"Tulloch","year":"2023","journal-title":"Vaccine"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"2080","DOI":"10.1080\/13607863.2021.2013433","article-title":"The experiences of care home staff during the COVID-19 pandemic: a systematic review","volume":"26","author":"Gray","year":"2022","journal-title":"Aging Ment Health"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"101","DOI":"10.1111\/1467-9566.00243","article-title":"System induced setbacks in stroke recovery","volume":"23","author":"Hart","year":"2001","journal-title":"Sociol Health Illn"},{"key":"ref21","doi-asserted-by":"crossref","first-page":"1","DOI":"10.4324\/9781003110873","volume-title":"Cambridge Social Ontology: An Introduction to Social Positioning Theory","author":"Slade-Caffarel","year":"2024"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"104719","DOI":"10.1016\/J.IJDRR.2024.104719","article-title":"Communicating with the public in emergencies: a systematic review of communication approaches in emergency response","volume":"111","author":"Hinata","year":"2024","journal-title":"Int J Disaster Risk Reduct"},{"key":"ref23","year":"2025"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"269","DOI":"10.1007\/S11115-022-00635-8","article-title":"Technocratic decision-making in times of crisis? The use of data for scientific policy advice in Germany\u2019s COVID-19 management","volume":"22","author":"Kuhlmann","year":"2022","journal-title":"Public Organ Rev"},{"key":"ref25","first-page":"1","volume-title":"Thematic Analysis, A Practical Guide Virginia Braun & Victoria Clarke","author":"Braun","year":"2020"},{"key":"ref26","first-page":"400","article-title":"Reframing clinician distress: moral injury not burnout","volume":"36","author":"Dean","year":"2019","journal-title":"Fed Pract"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"185","DOI":"10.31389\/jltc.53","article-title":"Did the UK government really throw a protective ring around care homes in the COVID-19 pandemic?","author":"Rajan","year":"2020","journal-title":"J Long Term Care"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"79","DOI":"10.3390\/systems14010079","article-title":"Redesigning long-term care policy using systems thinking in the post-pandemic era","volume":"14","author":"Tsasis","year":"2026","journal-title":"Systems"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1002\/wps.20311","article-title":"Understanding the burnout experience: recent research and its implications for psychiatry","volume":"15","author":"Maslach","year":"2016","journal-title":"World Psychiatry"},{"key":"ref30","first-page":"13","volume-title":"Street-Level Bureaucracy, Dilemmas of the Individual in Public Services","author":"Lipsky","year":"2010"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1162\/EUSO.a.87","article-title":"Managing down\u2019: \u2018pioneering\u2019 practice and professional discretion in the south-west of England care homes during the pandemic","author":"Sivi\u015f","year":"2026","journal-title":"Eur Soc"},{"key":"ref32","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1093\/acprof:oso\/9780198237907.001.0001","volume-title":"Epistemic Injustice: Power and the Ethics of Knowing","author":"Fricker","year":"2007"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"391","DOI":"10.1111\/jtsb.12251","article-title":"Organisation, emergence and Cambridge social ontology","volume":"50","author":"Slade-Caffarel","year":"2020","journal-title":"J Theory Soc Behav"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"66","DOI":"10.1017\/S1744133122000238","article-title":"Any lessons to learn? Pathways and impasses towards health system resilience in post-pandemic times","volume":"18","author":"Ewert","year":"2023","journal-title":"Health Econ Policy Law"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"560","DOI":"10.1111\/jtsb.12389","article-title":"The concept of function in social positioning theory","volume":"53","author":"Pratten","year":"2023","journal-title":"J Theory Soc Behav"},{"key":"ref36","volume-title":"The Iron Cage Revisted: Institutional Isomorphism and Collective Rationality in Organizational Fields Metrics and Impacts of Non-Profits View project Organizational Ecology View project","author":"Powell","year":"1986"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"173","DOI":"10.31389\/jltc.127","article-title":"Going through the eye of the storm\u2019: the impact of Covid-19 on the long-term dementia care workforce","author":"Capstick","year":"2022","journal-title":"J Long Term Care"},{"key":"ref38","doi-asserted-by":"publisher","DOI":"10.1093\/ageing\/afaf125","article-title":"The uncertainties and questions of care home residents, relatives and staff as a basis for evidence-based improvement and research","volume":"54","author":"Devi","year":"2025","journal-title":"Age Ageing"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"236","DOI":"10.1186\/s12877-023-03935-w","article-title":"Registered care home managers' experiences of responding to the national care home visiting guidance in England during the Covid-19","volume":"23","author":"Dixon","year":"2023","journal-title":"BMC Geriatr"},{"key":"ref40","doi-asserted-by":"crossref","DOI":"10.1093\/oso\/9780199256044.001.0001","volume-title":"Reassembling the social","author":"Latour","year":"2005"},{"key":"ref41","author":"Lipsky","year":""},{"key":"ref42","doi-asserted-by":"publisher","DOI":"10.1017\/S0144686X24000059","article-title":"Family carers\u2019 experiences of care home visiting restrictions during the Covid-19 pandemic: a relational autonomy perspective","author":"Dixon","year":"2024","journal-title":"Ageing and Society"},{"key":"ref43","doi-asserted-by":"crossref","first-page":"1","DOI":"10.4324\/9781003110873","volume-title":"Cambridge Social Ontology: An Introduction to Social Positioning Theory","author":"Slade-Caffarel","year":"2024"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"392","DOI":"10.1111\/jtsb.12332","article-title":"Rights and obligations in Cambridge social ontology","volume":"52","author":"Slade-Caffarel","year":"2022","journal-title":"Journal for the Theory of Social Behaviour"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"425","DOI":"10.1038\/s41581-020-0314-5","article-title":"Mental health of health\u2010care workers in the COVID\u201019 era","volume":"16","author":"Greenberg","year":"2020","journal-title":"Nature Reviews Nephrology"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1916166\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T12:15:56Z","timestamp":1789042556000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1916166\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,10]]},"references-count":45,"alternative-id":["10.3389\/fpubh.2026.1916166"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1916166","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,10]]},"article-number":"1916166"}}