Relationship between staff and quality of care in care homes: StaRQ mixed methods study.

Background: Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence. Objective(s): To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers. Design: Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model. Setting: English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings. Participants: Managers, residents, families and care home staff. Findings: Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged. Limitations: Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes. Conclusions: Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes. Study registration: This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

This study was about the relationship between staffing and quality in care homes. Almost half a million older people live in care homes in England. Why quality of care and quality of life for residents vary so much between and within homes is unknown, but staff and the ways they work are likely to be important. Researching staffing and quality is difficult: quality means different things to different people and a lot of things shape how quality feels to residents, families and staff. In the past, researchers have oversimplified the problem to study it and may have missed important influences. We took a more complex view. In five interlinked work packages, we collected and analysed: (1) research journal articles; (2) national data from different care homes; (3) data from a large care organisation to look at what it is about staffing that influences quality; (4) reports and ratings of homes from the Care Quality Commission; and (5) we looked at the networks between staff in homes that shape how quality improvement techniques might spread. We used theories about how our findings might be linked to plan for this data collection and analysis. The results were combined into something called a 'logic model' ­ a diagram and explanation that make it easier for managers, researchers and people interested in care homes to see how staffing influences quality. Staffing considerations that might improve quality include: not swapping managers too much; having sufficient and consistent staff for family-like relationships in homes and putting residents' needs first; supporting staff and giving them freedom to act; and key staff leading by example. Research examining care home quality should capture those aspects that mean the most to residents, their families and staff.

'Making the most of time during personal care': nursing home staff experiences of meaningful engagement with residents with advanced dementia.

OBJECTIVES: Dementia progressively affects cognitive functioning, including the ability to communicate. Those who struggle to communicate are often considered unable to relate to other people. Frontline care workers are in a position to connect with residents. However, we know little about their perspectives. The aim of this study was to understand how and when nursing home staff meaningfully engaged with residents with advanced dementia. METHODS: Semi-structured interviews, supplemented by informal conversations, were conducted with 21 staff from seven nursing homes. Inductive thematic analysis identified themes in the accounts. RESULTS: Four themes related to how staff engaged with residents with advanced dementia (initiating meaningful engagement, recognising subtle reactions, practising caring behaviours, patience and perseverance). Two themes related to when meaningful engagement occurred (lacking time to connect, making the most of time during personal care). CONCLUSION: A key barrier to implementing formal interventions to improve care is lack of staff time. Staff overcome this by using personal care time for meaningful engagement with residents. Their approach, developed through experience, is consonant with person-centred dementia care. Building on this, future research should use participatory approaches building on practice wisdom to further develop and evaluate meaningful engagement with residents with advanced dementia.

Leading by example: Nursing home staff experiences of what facilitates them to meaningfully engage with residents with advanced dementia.

OBJECTIVES: Meaningful connections promote the quality of life of people living with advanced dementia in nursing homes. However, evidence internationally suggests people living with advanced dementia in nursing homes spend the majority of time alone, with little contact with anyone. Frontline care workers are in powerful positions to meaningfully engage with residents, yet research to date has not focused on their experiences. The aim of this study was to explore the experiences of nursing home staff, specifically, what care workers feel enables them to meaningfully engage with residents living with advanced dementia. METHODS/DESIGN: Semi-structured interviews were conducted with 21 staff from seven nursing homes. Inductive thematic analysis was used. RESULTS: Four themes were important for facilitating care workers to meaningfully engage with residents with advanced dementia: support from managers and nurses, support from experienced care workers, a caring culture and an appropriate physical environment. CONCLUSION: Effective leadership was the key thread that ran throughout. It was evident that meaningfully engaging with residents with advanced dementia was hard, particularly for new or inexperienced care workers. Those with experience (of care work and the residents they cared for), as well as those in formal leadership positions played key roles in facilitating care workers to: perceive it was their role to connect, understand, accept and empathise with residents, understand the importance of getting to know residents' and express their own caring attributes. Future research should focus on empirically testing leadership models that promote meaningful engagement.

A qualitative exploration of the clinical presentation, trajectory, management and recovery of COVID-19 in older people: Learning from frontline staff experiences.

COVID-19 had a devastating impact on older people living in care homes. This study explored the clinical trajectory and management of COVID-19, as well as recovery of older people following infection during the early stages of the pandemic (May to August 2020). A two-phase exploratory qualitative study was used. Frontline staff with experience of caring for older people with COVID-19 were recruited to Phase 1, and senior care home operational and quality managers were recruited to Phase 2. During Phase 1 remote semi-structured interviews (n = 35) were carried out with staff working in care homes, hospital and community settings in England. During Phase 2, a remote consultation event was carried out with senior care home operational and quality managers (n = 11) to share Phase 1 findings and check resonance, relevance and gaps. Data were analysed using Framework Analysis. Older people with COVID-19 presented with wide ranging symptoms, and an unpredictable illness trajectory. The wide range of COVID-19 symptoms required timely testing and supportive interventions. Staff used different interventions to manage symptoms and reported uncertainties of how individuals would respond. In care home settings, health and social care staff needed to work together when administering interventions such as subcutaneous fluids or oxygen therapy. Alongside symptom management, supportive care focused on nutrition and hydration, social interaction, and maintaining physical activity to meet both physical and emotional needs. The effects of prolonged periods of social isolation and inactivity on the health and well-being of older people means rehabilitation is essential to enhance physical and emotional recovery, and to minimise impacts on cognition and function. The pandemic highlighted important areas for care of this population.

Understanding the staff behaviours that promote quality for older people living in long term care facilities: A realist review.

BACKGROUND: Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship. OBJECTIVES: To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents. DESIGN: A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities. SETTING: Long-term residential care facilities PARTICIPANTS: Long-term care facility staff, residents, and relatives METHODS: The realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups. RESULTS: 66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents' needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings. CONCLUSION: Leaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.

Recommended Common Data Elements for International Research in Long-Term Care Homes: Exploring the Workforce and Staffing Concepts of Staff Retention and Turnover.

The aim of this review is to develop a common data element for the concept of staff retention and turnover within the domain of workforce and staffing. This domain is one of four core domains identified by the WE-THRIVE (Worldwide Elements to Harmonize Research in Long-Term Care Living Environments) group in an effort to establish an international, person-centered long-term care research infrastructure. A rapid review identified different measurement methods to assess either turnover or retention at facility level or intention to leave or stay at the individual staff level. The selection of a recommended measurement was guided by the WE-THRIVE group's focus on capacity rather than deficits, the expected availability of internationally comparable data, and the goal to provide a short, ecologically viable measurement. We therefore recommend to measure staff's intention to stay with a single item, at the individual staff level. This element, we argue, is an indicator of staff stability, which is important for reduced organizational cost and improved productivity, positive work environment, and better resident-staff relationships and quality of care.