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‘Things Won’t Improve if they’re Just Left to Fester’: A Qualitative Study Exploring How UK Care home Staff Perceive and Experience Engagement in Health Research

Authors:

Madison Stephens ,

Falmouth University, GB
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Alec Knight

Kings College London, GB
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Abstract

Context: Care homes are challenging environments in which to conduct research and are under-represented within research literature compared to healthcare settings. This is concerning as research can improve organisational and individual outcomes. Evidence is scant on exploring how care home staff perceive and experience research engagement; the topic requires further inquiry.

Objective(s): To generate additional insights into how care home staff perceive and experience research engagement.

Methods: A phenomenological approach using structured micro-interviews with a convenience, snowball sample of 26 care home staff in one care home. An inductive approach using thematic analysis was employed to analyse interview data.

Findings: Most participants were unfamiliar with research, and cited time constraints, workload, and a lack of opportunity as barriers to participation. Despite their unfamiliarity, participants understood research to mean the attainment of knowledge and recognised positive and tangible outcomes as markers of successful research. Staff were generally unsure what would facilitate their engagement with research, although a few participants highlighted the role of the researcher as a determinant. Many care home staff in this study did not consider research to be part of their responsibility.

Limitations: The study was limited by being based on one case study organisation, possible selection bias amongst participants, and the inability to transfer findings beyond Cornwall.

Implications: More needs to be done to engage care home staff in research to improve their overall representation within research. More research is needed across different localities to replicate and validate the findings from this study.

How to Cite: Stephens, M. and Knight, A., 2022. ‘Things Won’t Improve if they’re Just Left to Fester’: A Qualitative Study Exploring How UK Care home Staff Perceive and Experience Engagement in Health Research. Journal of Long-Term Care, (2022), pp.268–276. DOI: http://doi.org/10.31389/jltc.137
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  Published on 08 Nov 2022
 Accepted on 22 Sep 2022            Submitted on 08 Feb 2022

Background

Internationally, research conducted in care homes is sparse (Katz, 2011) and underdeveloped (NIHR, 2017). A national survey in Scotland (Law, 2016) noted that only 7% of care homes had participated in research over a ten-year period. Accordingly, care homes are underrepresented in research (NHS Research Scotland, 2021), with reports of care home staff being unfamiliar with (Giné-Garriga et al., 2020) and hesitant towards research (Goodman et al., 2011). According to research funded by NIHR, care homes are complex and challenging environments in which to conduct research (Brooks et al., 2019). This is related to various barriers (Davies et al., 2014), including time constraints (Lam et al., 2018), limited resources, low staffing levels, and management issues (NIHR, 2021). These barriers are likely to affect the recruitment and retention of care home staff in research (Ersek et al., 2012). This is a clear concern because research can inform (Collingridge Moore et al., 2019) and improve health and long-term/social care (Hanney et al., 2013) and patient/resident outcomes (Austin, 2021).

Care homes have an important role in delivering health and social care (Robbins et al., 2013) to approximately 400,000 individuals in the UK (Laing-Busson, 2018). This figure is likely to rise alongside the ageing population (Kingston et al., 2018), which is expected to place greater demands on care homes (Deschodt et al., 2017). In 2015, the Prime Minister of the United Kingdom called for more research to be conducted in care homes (Department of Health, 2015), and this call remains relevant. According to the NIHR (2021), organisations that do not engage in research may fail to meet health and social needs. Therefore, it is important that care homes are engaged in research so that individuals now and in the future receive the best and most appropriate evidence-based care. To help achieve this, a deeper understanding is needed of how care home staff perceive research engagement, including throughout the Covid-19 pandemic (Law & Ashworth, 2022).

A search of Pubmed conducted in July 2021 focusing explicitly on the experiences and perceptions of care home staff with regard to research identified no relevant peer-reviewed publications, emphasising the paucity of evidence on this topic. To contribute to the research literature on the experiences and perceptions of research among care home staff, the present research addressed the following research question: “How do care home staff perceive and experience engagement with health research?

Methods

Methodological Approach

This study adopted a phenomenological methodology using a qualitative approach that aims to understand interactions occurring within the social world (Denney & Tewksbury, 2013). Qualitative approaches help to answer research questions related to perspective (Hammarberg et al., 2016) and thus were considered the most appropriate way to illuminate the perceptions and experiences of care home staff. To explore these perceptions, a structured interview guide consisting of seven open-ended questions was constructed:

  1. Please tell me about any previous experiences of research projects in the care home setting.
  2. What do you think is the purpose of research within care homes?
  3. What do you think prevents care home staff from engaging in research?
  4. What does research mean to you?
  5. What do you think helps care home staff engage in research?
  6. Please tell me what successful research would look or feel like in the care home setting.
  7. Please describe your professional role.

Ethical approval for this study was obtained from the Falmouth University Ethics Committee (RIEC 21 056).

Sampling and recruitment

This study was part of a wider project called ‘The Connected Healthcare Project’, which was funded by the European Space Agency and aimed to assess the acceptability of satellite-enabled technology within care homes. A single care home was selected for this study as the researchers had pre-established access and relationships with gatekeepers at the care home. This study was limited to one care home owing to the complexities of conducting research during Covid-19 (Research Authority, 2021), which restricted our ability to engage with and recruit from other care homes. For example, another care home in the region was invited to participate in the study but declined due to a lack of resources, which may have reflected the increased demands placed upon care home staff during the pandemic (Hanna et al., 2022).

A convenience, snowball sample of thirty-two staff working in a residential care home in Cornwall, England was invited in person to take part in the study. Six individuals declined to participate, citing a lack of time, an unwillingness to participate, or both. Twenty-six individuals (81.25%) were recruited for the study. Access to participants had been previously established, although interviewees were unaware of the purpose of this study before the interview and were not known to the researchers. While care home residents could have participated in the research (Backhouse et al., 2016), their inclusion would not have helped to answer the research question. Furthermore, the inclusion of residents would have required more stringent ethical approval procedures, which would have delayed or prohibited access to the care home in line with Covid-19 guidance. Lastly, the potential risks associated with including residents within the research, such as Covid-19 transmission, outweighed the benefits of their inclusion within the study. Before enrollment, all participants received verbal and written information about the study and had the option to decline participation and withdraw their consent at any point. No participants declined.

Data Collection

A structured interview guide was designed based on the experience of the research team. A simple, structured approach was chosen over a semi-structured approach to maximise the clarity of the research process for participants. This was an important consideration as care home staff are often unfamiliar with research (Giné-Garriga et al., 2020). Phenomenological interviews were used to explore individuals’ experiences and the meanings attributed to those experiences (Seidman, 2012) and, therefore, were an appropriate method to answer the research question. “Micro-interviews” that were short in length (Mertala, 2021) were considered an appropriate and transferable method. Originally piloted on children, this method was considered more sensitive than traditional interviews to time constraints that hamper the ability of care home staff to engage in research (Lam et al., 2018).

The method and interview guide could not be piloted amongst care home staff owing to difficulties accessing them during the Covid-19 pandemic. In total, 26 participants were interviewed by MS in the care setting between August and November 2021. Interviews were conducted in communal dining spaces where residents and staff were occasionally present, owing to a lack of private facilities and the need for staff to be readily available to residents. Interviews were audio-recorded with participants’ verbal and written consent. Despite participants having the opportunity to discuss answers freely, the mean interview length was four minutes. We anticipated that the interviews would be short, as care home staff are sometimes suspicious of researchers (Lam et al., 2018) and that it may have been the first exposure to research among the participants. Follow-up of participants was not feasible owing to the complexities of gaining access to staff, whose working patterns varied, and who were facing additional work demands whilst working through the pandemic. Anonymity was maintained by assigning each participant and their corresponding audio recording a random number. Interviews were transcribed verbatim by MS. Audio recordings were stored digitally in a password-protected file and deleted upon transcription.

Data analysis

An inductive, reflexive thematic analysis approach (Clarke & Braun, 2017) based on Grounded Theory techniques (Glaser et al., 1968) was used to derive common codes and themes within the data. Transcripts were read, re-read, coded, and organised into themes by MS using NVivo 11 for Windows (released in March 2020). Regular meetings were held with researchers from the Connected Healthcare Project to review the developing codes and to interpret and discuss themes so that thematic areas could be developed while avoiding other elements from being overlooked. Saturation was achieved when no new codes could be derived from the data per Urquhart (2012). Saturation can be achieved after twelve interviews (Guest et al., 2006), although more interviews were conducted in our study to address heterogeneity and increase the variety of responses. Validation of themes was sought from the care home manager, who had no additional comments regarding the accuracy of themes.

The following terms have been used to describe the data: ‘a few’ to describe less than 25% of participants; ‘some’ to refer to 25%–50% of participants; ‘many’ to refer to 50–75% of participants and ‘most’ to refer to over 75% of participants. Table 1 outlines the key characteristics of the sample. Most participants were female (n = 22), healthcare assistants (n = 15), and between 20–29 (n = 7) or 50–59 years old (n = 7).

Table 1

Participant demographics.


DEMOGRAPHIC CATEGORY N = 26 (%)

Gender

Female 22 (84.6%)

Male 4 (15.4%)

Age group

<20 years old 1 (3.8%)

20–29 years old 7 (26.9%)

30–39 years old 4 (15.4%)

40–49 years old 5 (19.2%)

50–59 years old
60–69 years old
7 (26.9%)
2 (7.7%)

Job role

Healthcare assistant 15 (57.7%)

Manager 1 (3.8%)

Deputy manager 1 (3.8%)

Chef 1 (3.8%)

Caretaker 1 (3.8%)

Customer relations administrator 1 (3.8%)

Activity coordinator 1 (3.8%)

Housekeeper 4 (15.4%)

Kitchen assistant 1 (3.8%)

Findings and analysis

Seven prominent themes were derived from the data: (1) Gaining a deeper understanding; (2) The attainment of knowledge; (3) Unfamiliarity with research; (4) Time constraints; (5) Confusion regarding what factors facilitate research; (6) Association between positive change and successful research; and (7) Recognition of caregiving as a professional responsibility. These themes are discussed in greater detail alongside minor themes in the following section.

What research means to care home staff

Most participants (n = 20) felt that research meant the attainment of a deeper understanding, by “looking at things from all different angles” and “getting as much information as you can.” A few participants (n = 3) appeared to associate research with professionals wearing “lab coats” researching diseases: “People in the labs like researching, I don’t know, like big things like cancer and all that malarkey, medically and science [sic].” (Participant 1324). Moreover, a few participants (n = 4) were unsure of what research meant to them: “I’ve never really thought about it, uh? I don’t really know.” (Participant 2695). The finding that most participants in this study felt that research meant ‘the obtainment of knowledge’ is consistent with previous findings (e.g., Popovic, 2003). Further, the influential role researchers have played during the Covid-19 pandemic may explain why some participants in this study associate researchers and research with the ‘white lab coat’ stereotype (Thomson et al., 2019).

Differences between job roles and the likelihood of being enrolled within health and long-term care research may explain why some care home staff were unable to describe what research meant to them. Nevertheless, this paper suggests that the meaning of research varies among care home staff, with most staff recognising it as an activity that seeks to gain information.

Care home staff and their perception of the purpose of research

Many participants (n = 14) perceived the purpose of research was to attain knowledge: “Finding out things that you wouldn’t normally be able to find out, you could look into things more deeply.” (Participant 2695). Research was seen as “educational” and as a vehicle that enabled the dissemination of information which enabled staff to “stay up to date”. Furthermore, some participants (n = 7) felt that the purpose of research was to identify areas for improvement: “things won’t improve if they’re just left to fester and don’t get looked at” (Participant 1598). A few participants (n = 3) elaborated on this and claimed that the objective of research was to promote good quality care and quality of life amongst residents, which suggests that care home staff have a broad understanding of the purpose of research.

Participants in this study echoed the idea that research can lead to improved outcomes (Royal College of Physicians, 2018), including the advancement of knowledge, identification of areas for improvement, and the promotion of good quality care (Wensing & Grol, 2019). Moreover, participants appeared to understand research from an outcome perspective rather than a process one, which diverges from the notion that research is explorative, descriptive, and explanatory (Babbie, 2013; Morris, 2006; Royse, 2004).

Care home staff and their familiarity with research

Most participants (n = 23) were unfamiliar with research, and a few (n = 4) reported that this study was their first exposure to being involved in research. “I’ve not ever been part of like a research sort of project within a care home [sic.] … This will be the first one.” (Participant 3482). One participant explained how they thought that no one had “bothered” to conduct research within the care home during the ongoing Covid-19 pandemic. Conversely, another participant explained how Covid-19 had brought about a “big project” in the care home. The few participants who considered themselves familiar with research (n = 6) recognised it as a process of data collection and dissemination within the care home: “There are handouts now and then for carers and residents to fill out and we have meetings here, which I guess would be classed as research” (Participant 1598).

These findings support evidence that care home staff are generally unfamiliar with research (Brooks et al., 2019). This may be in part attributable to the ongoing Covid-19 pandemic, which has hampered some research (Research Authority, 2021), whilst promoting research directly concerned with the Covid-19 pandemic (Omary et al., 2020). Moreover, these findings show a discrepancy in how research is understood, which may be due to expected differences in understanding between clinical and non-clinical staff within the care home. These disparities in understanding reinforce Iliffe and colleagues (2017), who claim that research is seen differently by care home staff compared to some other health and care colleagues. For instance, unlike the Department of Health (2019), which described research as an information-generating activity, participants in this study understood research as an information-seeking activity.

Barriers that prevent care home staff from engaging in research

A lack of time was perceived by some participants (n = 8) as a barrier that prevented care home staff from engaging in research: “Time. Cos [sic] as you see today, we’re just always on the go.” (Participant 3406).

Workload, resident acuity, inadequate staffing levels and “stigma” surrounding paperwork were considered barriers that prevented staff from engaging in research. Furthermore, a few participants (n = 4) highlighted “a lack of opportunity” as a barrier that prevents care home staff from engaging in research. Two participants elaborated on this, explaining how research tended to adopt a biomedical focus with the NHS being the place “they find all the answers” (Participant 2020).

Consistent with previous research (Davies et al., 2014 & Jenkins et al., 2016), most participants in this study highlighted time constraints as a barrier that prevents care home staff from engaging in research. According to a report by Age UK (2020), care home staff are overworked and manage demanding workloads (Launder, 2020), which reflects chronic staff shortages across the care sector (Ford, 2021). It is therefore perhaps not unsurprising that research in this context is perceived as “someone else’s business” (Royal College of Physicians, 2018).

Participants in this study described how they lacked the opportunity and capability to engage in research. These feelings may be exacerbated by disparities in how health and social care research is funded, with social care research receiving 92.8% less funding in 2019/20 compared to primary care research (National Institute of Health Research, 2021). This research reinforces the wider opinion that social care plays “second-fiddle” to acute services (Macdonald, 2021) and infers that care home staff may require increased opportunities and resources to engage with or promote research.

Determinants that promote research engagement amongst care home

Some participants (n = 8) were unsure what promoted research engagement amongst care home staff, owing to their unfamiliarity with research: “Um, I literally don’t know… I’ve not come across it like I said” (Participant 1324). Conversely, a few participants (n = 4) highlighted how the researcher influenced research engagement amongst care home staff: “Umm, somebody like yourself coming in, I would say, prompting us in the right direction… asking us questions” (Participant 3714). Furthermore, a few participants (n = 4) described how the determinants that promote research engagement amongst care home staff depended on the research question.

These findings suggest that care home staff are unaware of the determinants that promote research engagement, highlighting how research in care homes remains in its infancy (Williams, 2019). However, some participants in this study recognised that the researcher could promote research engagement amongst care home staff. This is consistent with Newington & Metcalfe (2014) who found that researchers’ personalities and knowledge influenced research participation, all highlighting how the views and beliefs of a researcher can influence participants’ decision to engage in research (de Salis et al., 2008).

Care home staff and their perception of ‘successful’ research

Some participants (n = 11) felt that successful research would result in “positive”, “physical” change and/or improvement: “It would look like an improvement in some way to the environment I guess.” (Participant 1598). A few participants (n = 5) felt that successful research would contribute toward a deeper understanding and professional development: “Anything that benefits them really and benefits us and our knowledge and progression” (Participant 2960). For some participants (n = 4) successful research would result in their voices “being heard”. A few participants (n = 2) felt that successful research would enable care home staff to become more aware of “how” and “where” to research.

These findings suggest that where care home staff have a view about successful research, they perceive it to be something that results in a change and/or improvement to clinical practice or their knowledge bases. This finding supports claims that successful research is dependent on change (Curtis et al., 2017) and is a transformative process (Trevors et al., 2012).

Participants in this study also felt that successful research would increase awareness of research processes and would improve participation within research amongst care homes staff. This suggests an expectation that research should be inclusive (Denegri, 2015; Richards, 2017).

Care home staff and the perception of their role

Not surprisingly, participants tended to see caregiving as the key responsibility associated with their role, particularly related to assisting residents with activities of daily living: “I do like the personal care and like getting them washed and dressed, um, assisting with feeding if they have like difficulties, and taking them to the toilet, getting them drinks.” (Participant 2020). A few participants (n = 4) understood their role as one that promoted emotional wellbeing amongst residents, including “making them happy”. Additionally, a few (n = 2) described their role as a developing one that included managerial responsibilities and being part of a wider team. One participant saw that their role was “to be seen as a fountain of knowledge” whilst another understood research to be part of their responsibility. These findings suggest that care home staff perceive their main responsibility to be in the delivery of care. In comparison, few participants perceived research to be within their remit, suggesting that research activity is not considered an important element for care home staff. These findings resonate with those from sources that highlight shortages of staff across the care sector (UK Commission for Employment and Skills, 2015), whereby 44% of social care managers and leaders consider their workforce to possess the “bare minimum” skills needed to do their core jobs (The Open University, 2021), let alone engage in research.

Discussion and Conclusions

This study has provided a snapshot of how a sample of UK care home staff perceive and experience research. Combined with existing evidence, this study can be used to inform future efforts to recruit care home staff to be more engaged with research. This study reiterates observations by Long (2017), who noted that care home staff face barriers to engaging in research, including time constraints, workload, and a lack of opportunity. Many staff in our study did not consider research to be part of their role and were largely unfamiliar with research and had not thought about factors that influenced their potential engagement. Staff in our study appeared to have a basic and generalised understanding of research and understood it as an activity that advanced knowledge and produced positive and tangible outcomes.

A strength of the study is that it has elicited open and honest responses from the under-researched population of care home staff with regard to their views and knowledge of research in their sector. Another strength of the study is that it has validated micro-interviews as an acceptable and practicable method for collecting data amongst care home staff. Micro-interviews were an effective method of eliciting rich data from care home staff, despite their short length, and could be transferable to other samples of long-term care staff who face time pressures with regard to participating in research studies.

Our study had the following limitations. Firstly, there may have been a selection bias among the interviewees who felt comfortable disclosing work-related information to an interviewer and registered nurse. Second, this study was based on a small sample of residential care home staff, which may limit the transferability of findings to other contexts. Replication and validation of the present findings are recommended. Although piloting methods was not possible in this study because of the constraints of the pandemic, methods should be piloted prior to data collection in future studies.

To address these limitations, more research on the topic is needed using a broader and larger sample of care home staff. Future research may wish to deploy an unstructured or semi-structured interview guide to uncover deeper insights into this topic. Moreover, future research may wish to enquire about the types of resources and study designs care home staff need to promote participation in research. Further research is needed on interventions to address the issues identified here to help care homes and staff within them to be more engaged with using and producing research evidence.

Researchers should anticipate barriers, particularly time constraints when designing future research studies engaging care home staff and be generous in their timeframes during the recruitment phase (Davies et al., 2014). Researchers may also consider using digital technologies to collect data to minimise the ‘stigma of documentation’ as this mode has shown to be suitable within an interview study (Charalambous & Goldberg, 2016). At a macro-level, social care researchers should take full advantage of opportunities, such as those available from an innovation and collaboration fund (HM Government, 2021), aimed at training and familiarising care home staff with research. Care homes and researchers should embrace the resources available within ENRICH, an NIHR initiative designed to promote research across care homes (NIHR, 2021). Although these recommendations are unlikely to embed a culture of research within care homes on their own, they may prove to be useful steps that avoid practice from being “left to fester.”

Additional File

The additional file for this article can be found as follows:

Supplementary File

Original transcriptions of participant interviews. DOI: https://doi.org/10.31389/jltc.137.s1

Acknowledgements

Thank you to the European Space Agency, funders of The Connected Healthcare Project which supported this work. Thank you also to Anna Mankee-Williams and Gwynedd Williams for their contributions in reviewing and interpreting the data.

Competing Interests

The authors have no competing interests to declare.

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