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Practice Based Approaches to Supporting the Work Related Wellbeing of Frontline Care Workers in Care Homes: A Scoping Review

Authors:

Lucy Johnston ,

School of Health and Social Care, Edinburgh Napier University, GB
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Cari Malcolm,

School of Health and Social Care, Edinburgh Napier University, GB
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Lekaashree Rambabu,

NHS Tayside/Edinburgh Medical School, University of Edinburgh, GB
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Jo Hockely,

Usher Institute, University of Edinburgh, GB
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Susan Shenkin

Usher Institute, University of Edinburgh, GB
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Abstract

The COVID-19 pandemic has reinforced the need to ensure that strategic and operational approaches to retain high quality, resilient frontline care home workers are informed by context specific, high quality evidence.

A targeted scoping review asked the question: what is the current evidence base for practice based approaches that support the work related wellbeing of frontline care workers in care homes? The aim was to map the extent and nature of the care home specific evidence base and identify key interventions, theories and practice components.

Thirty studies were included. Thematic synthesis identified the following four key themes: Culture of Care; Content of Work; Connectedness with Colleagues and Characteristics and Competencies of Care Home Leaders. Evidence for best practice in supporting care home work related wellbeing is extremely limited, of variable quality and lacks generalisability.

Overall, the evidence base was found to be theoretically, empirically and practically fragmented and as a result, there is at present, no consensus about which areas of work related wellbeing, if addressed, would have most impact. Compounding this lack of coherence, is the limited specificity of the studies. The implicit nature of the current evidence base is also a result of the limited number of care home specific studies, their variable focus and quality, and the marked heterogeneity in the outcome measures and related indicators used by different studies.

This scoping review has distilled important areas that warrant further exploration and research from within a very limited and diffuse evidence base, for example, the potential of Person Centred Care (PCC) as a protective mechanism for both resilience and retention and the more nebulous concepts of support and job satisfaction.

The insight provided by the scoping review will inform future strategic and operational approaches to retain high quality, resilient frontline care home workers. However, the evidence base must move from its current state of implicitness to one of detailed explication. Future research should focus on high quality, adequately powered and co-designed intervention studies to determine which practice-based approaches are of most importance, how they ‘work’ or ‘don’t work’ alone or in combination to support the work related wellbeing of frontline care workers in care homes.

How to Cite: Johnston, L., Malcolm, C., Rambabu, L., Hockely, J. and Shenkin, S., 2021. Practice Based Approaches to Supporting the Work Related Wellbeing of Frontline Care Workers in Care Homes: A Scoping Review. Journal of Long-Term Care, (2021), pp.230–240. DOI: http://doi.org/10.31389/jltc.66
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  Published on 09 Aug 2021
 Accepted on 22 Jun 2021            Submitted on 23 Nov 2020

Background

Over the last year, care homes have borne witness to a pandemic that has disproportionately and devastatingly affected residents (Gordon et al., 2020) and the workforce. In the UK, during the first 10 weeks of the pandemic alone, care home deaths increased by 220% (Bone et al., 2020). Many deaths were unexpected (before their time), lockdown measures kept families apart, and it was difficult for staff to find sufficient time and space to process these bereavements and their own grief (McGilton et al., 2020).

Given the prolonged nature of the pandemic, this workforce is at even greater risk of work-related stress, burnout, moral distress, and detrimental psychological effects as they continue to endure considerable and changing work demands, anxiety, bereavement, and grief (Bauer et al., 2020; Billings et al., 2020; Devi et al., 2020a; Gordon et al., 2020; Lapid et al., 2020; McGilton et al., 2020).

Yet the need to safeguard the mental wellbeing of those who work in adult social care, and care homes in particular, was a global problem long before COVID-19 (Armstrong & Jansen, 2015; Costello et al., 2020; Pijl-Zieber et al., 2016; Raj, 2010; Yeatts, 2018). The pandemic has only served to intensify the need to ensure that the mental wellbeing of vital frontline care home staff is safeguarded and that they are supported to remain in their roles delivering high quality and compassionate care to older people.

Much of the research and reviews that have emerged recently around the impact of COVID-19 on well-being focussed generically on health and social care overall, or specifically on hospital-based staff (Heath et al., 2020; McFadden et al., 2021; Muller et al., 2020; Pollock et al., 2020). It is unclear whether the developing evidence base sufficiently addresses the ‘unique’ (Billings et al., 2020), ‘special’ (Devi et al., 2020a), and multi-faceted context of care homes or the staff who work in them. The majority of direct personal and social care is provided to residents by staff who are not registered nurses. They have different training, skills, and duties compared to the registered nurses they work alongside. Moreover, in contrast to registered nurses, care workers in care homes are less likely to have connections to professional bodies or organisations.

Prior to the pandemic, a significant number of studies of care home staff had looked at staying well and remaining in care home-related work from the perspective of long-term structural, socio-economic, and geographic factors, such as labour market dynamics, the gender/age make-up of the workforce, long and unsocial working hours, low pay, and status (Health Foundation, 2017; Rosen et al., 2019; VonDras et al., 2009). However, less was understood about what practice-based solutions to supporting care workers worked well and were effective, and what had been reported was limited and of variable quality (Scottish Care, 2019).

To fill this identified gap, we undertook a targeted scoping review to answer the following question: what is the current evidence base for practice-based approaches that support the work-related wellbeing of frontline care workers in care homes? The aim was to map the extent and nature of the care home-specific evidence base and identify key interventions, theories, and practice components that could inform the implementation of best practice and support strategies and that could guide research priorities moving forward.

Methods

Terminology and definitions used

To meet the review aims we had to first address the terminology and concepts within not only wellbeing and workforce literature, but also the specifics of the workforce and care setting we were targeting.

In this article, we refer to the term care home work-related wellbeing as a way to encompass and convey ‘resilience’ (Scoloveno, 2016), including related concepts of, for example, emotional stress, psychological and mental health and wellbeing, fatigue, anxiety, depression, distress, and work-related burnout and workforce retention factors or indicators of work-related wellbeing, such as absenteeism, low staff morale, reported staff intentions to leave their job, high staff turnover, and difficulties for recruitment.

We aimed to focus exclusively on those staff within care homes who have responsibility for providing direct care to residents but are not registered nurses. Across the UK and internationally this workforce is referred to using a range of job titles and roles, for example care worker, direct care workers (DCWs), certified nursing assistants (CNAs), and licensed practical nurses (LPNs). For purposes of this review, we refer to this group as frontline care workers (FCWs).

We focused on care homes for older people (people aged 65 or over). To ensure our search strategy would capture articles of relevance, we based it upon an approach recommended by Burton et al. (2017) and utilised a range of terms, such as nursing home, residential aged care facilities, and long term care facilities.

Scoping review methodology

A rapid scoping review using systematic searching methods and utilising recognised methodological frameworks (Arksey & O’Malley, 2005) and reporting guidelines (Tricco et al., 2018) was conducted. There are five stages to the scoping review framework: identification of research question(s); identification of relevant studies; study selection; charting the data; and collating, summating, and reporting the findings.

Stage 1 – Identification of the research question

The research question guiding this review was what is the current evidence base for practice-based approaches that support the work-related wellbeing of frontline care workers in care homes?

Stage 2 – Identification of relevant papers

An initial search plan was developed (LJ, CM). A senior subject specialist librarian (SM) further developed and executed the search strategy.

Eight databases (MEDLINE, PubMed, PsycINFO, Embase, MedRxiv, CINAHL, ASSIA, Social Science Premium) were searched for literature from 2010 onwards. A ten-year review period allowed us to assess both overall quality and direction of the literature and recent evidence and policy in this field. Grey literature was located by applying the same search strategy principles. Internet searches of Google, Google Scholar, and OpenGrey were undertaken. The websites of organisations and networks pertinent to health and social care were searched as were two international COVID-19 specific sites (LitCOVID (NLM) and the WHO COVID-19 database). The search was undertaken in early June 2020 and repeated on July 16, 2020, to ensure emerging evidence was captured. A sample of the MEDLINE search strategy is outlined in Supplementary File 1. This strategy was adapted for the other databases where necessary.

Stage 3 – Study selection

Results of the database search were initially screened for relevance by reviewing the title and abstract to ensure the inclusion and exclusion criteria were met (Table 1). This was conducted independently by three members of the project team (SM, LJ, CM). Full text versions of papers meeting the inclusion criteria were then accessed and reviewed independently by three reviewers (LJ, CM, LR). Where there was no consensus for inclusion/exclusion, a final decision was made by the lead author (LJ).

Table 1

Inclusion and Exclusion Criteria.

Inclusion Exclusion

Published in English Study protocols
Published between 2010–2020 Reporting only on prevalence/measurement
Setting is care homes for older people Other residential settings, for example setting for physical/learning disabled adults
Practice-based approaches and interventions to resilience and/or retention and explicitly states that it is of relevance to care home staff who provide direct care to residents Evidence concerning resilience or retention, which only includes or is only of relevance to registered nursing staff within care homes
Reports on findings or outcomes from evaluations of pilots, initiatives, activities, tests of change, QI programmes undertaken in care homes for older people Discussions of conceptual frameworks or theoretical models of resilience and/or retention

Stage 4 – Charting the data

Relevant data was extracted from each paper and included: author(s), publication year, country of origin, study/paper design or methodology, aim, indicators and measures, participants, reported findings, and key recommendations. In accordance with scoping review methodology and given both the wide range of study designs included and the limited timeframe in which to undertake this review, a quality appraisal/risk of bias assessment of the evidence was not undertaken (Arksey & O’Malley, 2005; Levac et al., 2010; Tricco et al., 2018).

Stage 5 – Collating, summating and reporting findings

We undertook a thematic synthesis adopting the three-stage method set out by Thomas and Harden (2008). LR coded the extracted data, organising these into descriptive themes, then reviewers (LJ, LR, CM) discussed the meaning of the descriptive themes as they related to the review question and drew out similarities, dissimilarities, and patterns. Finally LJ developed analytical themes, which were discussed and further refined by the whole team till consensus was reached (LJ, CM, LR, JH, SS). The final results were reported through a narrative description of themes and a table summarising the contribution of each paper to the analytical themes.

Results

Papers identified

Review of the title and abstract resulted in the initial inclusion of 222 papers. Full text versions of these papers were then considered for inclusion in the review and resulted in the inclusion of 29 papers. The reference lists of the included articles were hand searched for further studies meeting the inclusion criteria and resulted in one additional paper. Therefore, a total of 30 papers were included in this scoping review. The PRISMA flowchart (Figure 1) illustrates the search strategy and paper selection process.

Figure 1 

PRISMA flowchart illustrating the search strategy and paper selection process.

Characteristics of included papers

Characteristics of the included papers are outlined in Supplementary File 2. In this section we set out the results of the review focussing upon the country of origin, setting, participants, study design, and paper type. We also detail the range of practices, approaches, and components of care home work-related wellbeing extracted from the included papers.

Country of origin

Nine papers originated from the USA (Berridge et al., 2018; Berridge et al., 2020; Boerner et al., 2017; Castle, 2013; Choi & Johantgen, 2012; Dreher et al., 2019; Lane & McGrady, 2018; Yeatts et al., 2010; Yeatts et al., 2018), five from the UK (Billings et al., 2020; British Geriatrics Society, 2020; Moss & Meyer, 2014; Rajan & Mckee, 2020; Scottish Care, 2019), four from Canada (Berta et al., 2018; Bethell et al., 2018; Braedley et al., 2018; Caspar et al., 2020), three from Sweden (Beck et al., 2015; Ericson-Lidman & Ahlin, 2017; Wallin et al., 2012), and two from Switzerland (Gaudenz et al., 2019; Schwendimann et al., 2016), Japan (Fukuda et al., 2018; Nakanishi & Imai, 2012), Portugal (Barbosa et al., 2015a; Barbosa et al., 2015b), and Australia (King et al., 2013; McNeil et al., 2019). One paper was published by an international organisation (World Health Organisation, 2020).

Setting and participants

Almost half the papers (n = 14) had only FCWs as the participants (Barbosa et al., 2015b; Beck et al., 2015; Berta et al., 2018; Bethell et al., 2018; Boerner et al., 2017; Caspar et al., 2020; Choi & Johantgen, 2012; Dreher et al., 2019; King et al., 2013; McNeil et al., 2019; Nakanishi & Imai, 2012; Wallin et al., 2012; Yeatts et al., 2018; Yeatts et al., 2010), and six papers included all care home staff, comprising both registered nurses and what we have termed FCWs (Braedley et al., 2018; Ericson-Lidman & Ahlin, 2017; Fukuda et al., 2018; Gaudenz et al., 2019; Schwendimann et al., 2016; Scottish Care, 2019). Three papers included care home administrators/managers (Berridge et al., 2018, 2020; Castle, 2013), and in one paper, participants were the managers and directors of care homes (Rajan & Mckee, 2020).

Study design and paper type

Five papers reported pre-test/post-test evidence (Barbosa et al., 2015b; Beck et al., 2015; Dreher et al., 2019; Ericson- Fukuda et al., 2018; Lidman & Ahlin, 2017). Of these, one was a quasi-randomised comparative trial (Fukuda et al., 2018).

All intervention studies identified in the scoping review reported on the results of an educational intervention on wellbeing at work (Supplementary File 3).

Overall the majority (n = 25) were empirical research, of which 15 were cross-sectional survey studies (Berridge et al., 2018, 2020; Berta et al., 2018; Bethell et al., 2018; Castle, 2013; Choi & Johantgen, 2012; Gaudenz et al., 2019; King et al., 2013; McNeil et al., 2019; Nakanishi & Imai, 2012; Rajan & Mckee, 2020; Schwendimann et al., 2016; Wallin et al., 2012; Yeatts et al., 2010, 2018).

Evidence derived from qualitative approaches—interviews with individuals, group discussions—were reported in Caspar et al. (2020); Boerner et al. (2017); Braedley et al. (2018); and Scottish Care (2019). Our scoping identified three reviews of relevant literature: a systematic review of how person-centred care approaches could impact stress, burnout, and job satisfaction of staff caring for people with dementia in residential aged care facilities (Barbosa et al., 2015a), a narrative review of the extent of emergency preparedness of long-term care facilities (Lane & McGrady, 2018), and a care home research briefing within which a review of evidence on ‘keeping the workforce fit for purpose’ was reported (Moss & Meyer, 2014).

Three papers consisted of COVID-19 specific guidance documents or recommended good practice for care homes (Billings et al., 2020; British Geriatrics Society, 2020; World Health Organisation, 2020). Whilst they all addressed managing various aspects of the pandemic within care homes, such as meeting residents’ needs and maintaining infection control, they all included recommendations and/or principles for supporting the mental health and well-being of care home staff (Billings et al., 2020; British Geriatrics Society, 2020; World Health Organisation, 2020).

Range of practices, approaches, and components of care home work-related wellbeing

Many different practices, approaches, or intervention components were identified, ranging from self-care behaviours of individual staff members (Billings et al., 2020; Dreher et al., 2019) to the overall organisational environment and context within which these individuals work (Billings et al., 2020; King et al., 2013; Lane & McGrady, 2018; Moss & Meyer, 2014; Yeatts et al., 2018). Organisational resilience was the specific focus of a 2018 report from the USA reviewing aspects of nursing home resilience in relation to emergency preparedness (Lane & McGrady, 2018).

Seven papers proposed that job satisfaction was a key factor in work-related wellbeing. Of these, five papers considered it to be an important factor in retaining staff (Beck et al., 2015; Berta et al., 2018; Bethell et al., 2018; Choi & Johantgen, 2012; King et al., 2013) and one in fostering staff resilience (Schwendimann et al., 2016). The seventh paper investigated determinants of job satisfaction (Wallin et al., 2012) through a survey of 225 FCWs and reported various aspects of work content and work climate/culture as being of importance, in addition to what they termed ‘organisational and environmental support’.

Identified Themes

Given the diverse and diffuse range of practice-based concepts and practice components elicited from the review, we undertook a thematic analysis that provided further insight into the extent and nature of evidence-based practices and interventions that support the work-related wellbeing of care staff in care homes for older people. Four analytical themes were identified: Culture of Care, Content of Work, Connectedness with Colleagues, and Characteristics and Competencies of Care Home Leaders. Table 2 indicates how the included papers contributed to the development of each theme.

Table 2

Contribution of each paper to analytical themes (n = 30).

Source Content of Work Connectedness with Colleagues Competencies/Characteristics of Leaders Culture of Care

Barbosa et al. (2015a) x
Barbosa et al. (2015b) x
Beck et al. (2015) x
Berridge et al. (2018) x x x
Berridge et al. (2020) x x
Berta et al. (2018) x x
Bethell et al. (2018) x
Boerner et al. (2017) x x x
Braedley et al. (2018) x x x
Caspar et al. (2020) x x
Castle (2013) x
Choi & Johantgen (2012) x x
Dreher et al. (2019) x x
Ericson-Lidman & Ahlin (2017) x
Fukuda et al. (2018) x x
Gaudenz et al. (2019) x x x
King et al. (2013) x x
Lane & McGrady (2018) x x x
McNeil et al. (2019) x x
Moss & Meyer (2014) x
Nakanishi & Imai (2012) x x x
Rajan & Mckee (2020) x x x
Schwendimann et al. (2016) x x
Scottish Care (2019) x x x
Wallin et al. (2012) x x x
Yeatts et al. (2010) x x x
Yeatts et al. (2018) x
British Geriatrics Society (2020) x
Billings et al. (2020) x x x
World Health Organisation (2020) x

Culture of care

This theme relates to two aspects of culture: the organisational culture and the care culture within the care home.

Three cross-sectional studies found that organisational factors and policies were associated with wellbeing, job satisfaction, or overall retention of staff. Work schedules and conditions can affect job satisfaction of care workers (King et al., 2013). Yeatts et al. (2018) found that levels of burnout were associated with organisational policies, such as providing sufficient resources to direct care workers (e.g., towels, gowns), making training accessible, offering fair pay, and adequate staffing levels. Higher nursing home occupancy and lower administrator turnover were associated with greater retention of ‘certified nursing assistants’ (Berridge et al., 2018).

Feeling valued, respected, or recognised, is associated with care home work-related wellbeing. A number of papers reported on how being respected, feeling respected and valued, and receiving recognition can have a positive impact on care staff (Gaudenz et al., 2019; King et al., 2013; Moss & Meyer, 2014; Nakanishi & Imai, 2012; Rajan & McKee, 2020; Yeatts et al., 2018).

Intention to leave among personal care assistants in Australia was increased when they felt undervalued (King et al., 2013). The perception of being valued by an employer was found to be significantly associated with job satisfaction (Choi & Johantgen, 2012). An online pilot survey conducted by Rajan and Mckee in June 2020 found that community donations and letters of appreciation were a mainstay of support for staff during the first months of the pandemic (Rajan & McKee, 2020), suggesting the value of positive care culture within homes.

A number of papers in this review draw a specific connection between a care home’s care practices and care culture. For example, Beck et al. (2015) investigated the effects of workshops on palliative care approach and on staff reported levels of strain, job satisfaction, and view of leadership, and Wallin et al. (2012) focussed on person-centred care (PCC) in relation to work-related wellbeing and reported on the positive benefits to staff. Two studies looked at the relationship between the provision of PCC training to staff and reported stress, burnout, and job satisfaction (Barbosa et al., 2015a; Barbosa et al., 2015b).

Moss and Meyer (2014) highlight the importance of relationship-centred care in providing staff with motivation and job satisfaction. Boerner et al. (2018) suggest that the way in which person-centred care is different from a task-orientated culture offers ‘a psychological defence mechanism against anxiety’, giving have a ‘protective effect’ on FCWs. Within two studies it is the nature and extent of the relationship between staff and residents that is associated with work-related wellbeing. Berridge et al. (2018) reported that the hours a FCW spends each day with residents is also important. This was supported by the work of Castle (2013), who reported that staff being able to consistently work with and care for the same residents was recognised as beneficial and of value.

Dreher et al. (2019) found that retention rates improved if awareness of compassion fatigue and self-care strategies amongst staff was increased. The study considered that such awareness would help FCWs understand and better meet the complex care needs of residents.

Content of work

The overall design of work content was highlighted as being associated with work-related wellbeing (Yeatts et al., 2018). How and which tasks are allocated will determine how much time staff spend with residents, and this was reported as a positive factor in staff retention by two papers (Berridge et al., 2018; Castle, 2013).

Nakanishi and Imai (2012) found that intention to leave was associated with the extent to which FCWs had discretion in how they used their skills. Having a variety of opportunities to apply the skills they possess was regarded as a measure of the quality of their role (Nakanishi & Imai, 2012). Similarly, Braedley et al. (2018) identified that having autonomy in deciding how and when to undertake required tasks was of importance to work-related wellbeing. The degree of staff empowerment as an associated factor was reported in three papers (Berridge et al., 2018; Berridge et al., 2020; Lane & McGrady, 2018) as was FCWs being involved in care decisions (Braedley et al., 2018). A lack of variety of tasks and work content resulting in skills being underused were found to have a negative impact on retention (King et al., 2013; Nakanishi & Imai, 2012).

Connectedness with colleagues

Having positive one-to-one relationships with work colleagues (Casper et al., 2020; Gaudenz et al., 2019; King et al., 2013; Nakanishi & Imai, 2012; Schwendimann et al., 2016) is reported as being associated with resilience and retention. More specifically, three papers identified the absence of conflict in these relationships as important (Gaudenz et al., 2019; King et al., 2013; Schwendimann et al., 2016), and four others highlight the importance of a FCW’s relationship with their immediate supervisor (Berta et al., 2018; Bethell et al., 2018; Choi & Johantgen, 2012; Nakanishi & Imai, 2012).

Team working was reported by eleven of the papers in the review (Barbosa, 2015a; Berridge et al., 2018; Berridge et al., 2020; Billings et al., 2020; Braedly et al., 2018; Casper et al., 2020; Gaudenz et al., 2019; Rajan & Mckee, 2020; Schwendimann et al., 2016; Scottish Care, 2019; WHO, 2020). Reciprocity (Casper et al., 2020) and effective communication (Braedley et al., 2018) were specified as contributing to good team working. No other detailed information was reported to better define which particular aspects of team working are most associated with resilience and retention. Three papers spoke of team working beyond staff groups as being of importance, indicating the value of wider multi-disciplinary or multi-sector teams (Billings et al., 2020; Scottish Care, 2019; WHO, 2020).

Characteristics and competencies of leaders in care homes

Three studies reported a strong relationship between leadership and retention of staff (Berridge et al., 2020; Gaudenz et al., 2019; Schwendimann et al., 2016). Positive leadership was also suggested to contribute to a low stress of conscience, with nursing assistants better able to provide care that corresponded to their own conscience when there was effective leadership (Wallin et al., 2015).

Two studies, one including nursing home care workers and the other with nursing administrators, both reported a strong relationship between leadership and retention of staff (Berridge et al., 2020; Gaudenz et al., 2019). In the study by Gaudenz et al. (2019), staff intention to leave showed strong inverse relationships with supportive leadership and affective organizational commitment and weaker positive relationships with stress due to workload, emotional exhaustion, and care worker health problems.

Care workers with higher overall intention to leave reported lower leadership ratings (Gaudenz et al., 2019). Berridge et al. (2020), in their survey of nursing home administrators, reported greater leadership and staff empowerment levels were associated with high retention of nursing assistants. In one large cross-sectional study, job satisfaction was found to increase four times with each point increase in leadership rating on a 4-point Likert-type scale (Schwendimann et al., 2016).

Bethell et al. (2018), Gaudenz et al. (2019), and Schwendimann et al. (2016) all suggest the need for leadership training for home managers and those in middle management positions. Two further papers highlighted the need to ensure leaders possess the skills to embed good practice post training (Beck et al., 2015; Yeatts et al., 2010).

Discussion

This review posed the question what is the current evidence base for practice-based approaches that support the work-related wellbeing of frontline care workers in care homes? A key finding is that the evidence is extremely limited. Only one systematic review was retrieved, focussing on the specific care practice of person-centred care, and the small number of intervention studies are inconclusive. Moreover, whilst multiple factors associated with supporting care home work-related wellbeing were identified, practice based approaches have either been insufficiently untested or results are inconclusive.

Our aim was to map the extent and nature of the care home-specific evidence base and identify key interventions, theories, and practice components relevant to work-related wellbeing. This scoping review illustrates that the current evidence base is unable to reliably and effectively inform best practice given the range of issues addressed, methodological weaknesses, and lack of specificty. Overall causal insights are obscured by this clutter, and the evidence base lacks overall coherency.

Through mapping and synthesising the available evidence within four analytical themes, the scoping review has highlighted the organisational and cultural theories referred to as underpinning some of the reported associations and identified the multiplicity of different practices, emphases, and components of work-related wellbeing that have been utilised both within and across the current evidence base. For example, using the concept of leadership, the review identified that in addition to the skills or competencies of leaders, management and leadership style are also important (Beck et al., 2015; Berridge et al., 2018). Other papers highlight further desirable characteristics of leaders. These include, for example, being compassionate (Billings et al., 2020); positive (Wallin et al., 2012); supportive (Berta et al., 2018; Bethell et al., 2018; Boerner et al., 2017; Choi & Johantgen, 2012; Schwendimann et al., 2016); visible (Rajan & McKee, 2020), inclusive and responsive (Caspar et al., 2020). These definitions of leadership lack specificity and as such will limit the extent to which effective leadership practices can be designed, integrated into care home practice development, and most importantly, sustained.

Our thematic synthesis mapped what appears to be some clustering of evidence around four key themes: culture of care, content of work, connectedness with colleagues, and the characteristics and competencies of care home leaders. Evident within each theme is the importance of how people approach their jobs and interact with others whilst at work. The results of this review have therefore served to further highlight the fundamentally human and interpersonal nature of care home wellbeing at work. Within care homes, the wellbeing of staff is inextricably linked to that of the residents they care for; however, no study involved residents. Effective and enduring solutions cannot solely target individual staff but should encompass the whole care setting, including social care recipients/residents and their families. As such, they must then be developed in-context and in-situ (Bunn et al., 2020; Davies et al., 2011; Killett et al., 2016). This presents an opportunity to focus on a targeted, tailored, whole-system approach to work-related wellbeing for care home staff. This is consistent with recommendations for wellbeing interventions for health care workers that advocate a holistic and whole-system approach (Brand et al., 2017; De Kock et al., 2020).

Overall, the evidence base was found to be theoretically, empirically, and practically fragmented, and as a result, there is at present no consensus about which areas of work-related wellbeing, if addressed, would have the most impact. Compounding this lack of coherence is the limited specificity of the studies. The implicit nature of the current evidence base is also a result of the limited number of care home-specific studies and their variable focus and quality and the marked heterogeneity in the outcome measures and related indicators used by different studies. For example, although all five intervention studies looked at educational/training aspects of care practices and skills in relation to wellbeing at work, their focus and selected outcome measures varied. Thirteen different inventories or measurement tools were used across the five studies. This problem is not exclusive to care home staff, and defining the concepts and measures of most use for work-related wellbeing in all health and social care settings and professions should be a priority (Baxter et al., 2009).

Strengths and Limitations

Recognised methodological frameworks for undertaking scoping reviews were followed, and the involvement of a specialist librarian (SM) and three independent reviewers are key strengths of this work.

This rapid review is the first to our knowledge that focusses solely on FCWs in care homes. It addresses an under-researched staff group and provides a much-needed and targeted review of available evidence of how they can best be supported. It incorporates what was known pre-COVID and also what was recommended to be helpful during the pandemic.

This review purposefully examined only the evidence available for practice-based support for FCWs caring for older people in care homes. As such it does not encompass other staff groups that are critical to the delivery of high quality care and the resilience and retention of FCWs—most importantly, registered nurses. It has also excluded broader aspects of recruitment and retention, such as pay; demographic issues, such as age and gender; and geographical demographics that will affect the labour market. Only studies published in English were included as time and budget constraints did not allow for translation of papers.

Conclusion

Overall, the results of this review highlight that multiple predictors and indicators of care home work-related wellbeing have been identified but not rigorously tested. It has distilled important areas that warrant further exploration and research from within a very limited and diffuse evidence base: for example, the potential of PCC as a protective mechanism for both resilience and retention and the more nebulous concepts of support and job satisfaction.

Although the existing evidence does provide insight into such promising avenues, at present it offers less to help develop our understanding of how best to construct services and systems that can be implemented within care homes.

The insight provided by the scoping review could inform future strategic and operational approaches to retain high quality, resilient frontline care home workers. However, the evidence base must move from its current state of implicitness to one of detailed explication. Only then can it inform intervention development, implementation strategies, and meaningful indicators of success. This is particularly important now following the COVID-19 pandemic, which has exacerbated the issue and further emphasised the critical need to support and safeguard residents and staff. Future research should focus on high quality, adequately powered, and co-designed intervention studies to determine which practice-based approaches are of most importance, how they work or don’t work alone or in combination to support the work-related wellbeing of frontline care workers in care homes.

Additional Files

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

Supplementary File 1

Medline search strategy (EBSCO). DOI: https://doi.org/10.31389/jltc.66.s1

Supplementary File 2

Characteristics of included papers (n = 30). DOI: https://doi.org/10.31389/jltc.66.s2

Supplementary File 3

Intervention Studies included with outcome measure used (n = 5). DOI: https://doi.org/10.31389/jltc.66.s3

Competing Interests

The authors have no competing interests to declare.

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