Methods of data collection and analysis

We worked with stakeholders, including nursing home staff and our Carer Reference Panel (CRP), to develop and adapt the INTERACT tools for use in the UK.

The following were conducted:

1. Co-applicant specialists in geriatric medicine (JY) and primary care (LR) reviewed care pathways identified in a search for care pathways (see Appendices 1 and 2). This led to version 1 of the care pathway.
2. We obtained expert panel input via e-mail on this version of the care pathway (see Appendix 3). Experts included three international advisory group members, two members of the British Geriatrics Society and three members of the Royal College of General Practitioners. This input was reviewed by John Young and Louise Robinson, and led to version 2.
3. We held a consensus workshop with 17 stakeholders with diverse areas of expertise, including eight nurses (four community/district nurses, three nursing home nurses and one nurse consultant), two nursing home managers, three care assistants, one geriatrician and three family members (see Appendix 4). This led to the final draft of the care pathway.

Limitations

The main limitation was the limited amount of previous research to guide our approach. Only 22 papers were identified in the literature review. Overall, the quality of intervention studies was rated as being highly variable. There was a lack of robustly conducted RCTs (only two trials were rated as being of ‘strong’ quality). Insufficient attention was paid to key methodological issues, particularly the clustering effect within nursing homes. Furthermore, there were few studies conducted in the UK, thereby having questionable relevance to the UK context.

Key finding

We identified care pathways for ACSCs in nursing homes for our four conditions (respiratory infection, exacerbation of CHF, UTI and dehydration) and adapted them in consensus co-design workshops with staff and family carers. We developed a care pathway to facilitate assessment and diagnosis of the four index conditions from existing care pathways used to facilitate diagnosis and treatment of health conditions in care home residents. The final version of the care pathway is presented in Appendix 5.

Inter-relationship with other parts of the programme

The care pathway was one of three intervention tools that were included in the feasibility study.

Methods for data collection and analysis

We used three methods of data collection: semistructured interviews, rapid research review and consensus-building.

Any limitations

There was a limited literature to inform us about the knowledge and skills required for nursing home care assistants and nurses to achieve early detection, assessment and reporting of acute changes in residents’ health.

Key findings

We derived a set of key knowledge and skills for nurses (see Appendix 8) and for care home staff and family members that are required for early detection of the four ACSCs. These included:

• knowledge of how ACSCs may manifest
• ability to detect these changes during daily care
• knowledge of residents’ medical conditions, care plans and their baseline behaviour and symptoms
• continuing assessment skills
• leadership skills
• communication skills.

Inter-relation with other parts of the programme

We examined the use of the knowledge and skills matrix in our feasibility study. We expected Practice Development Champions (PDCs) would use it to conduct a gap analysis and to direct care staff and family members to learning resources that could help to address these gaps.

Methods for data collection

We made detailed notes of the consensus workshop discussions and participants generated written notes.

Method for data analysis

We analysed the notes, along with written materials generated by the participants, looking for key themes.

Key findings

The criteria for PDCs were thought to be appropriate. Participants identified situations in which there could be gaps in coverage of staff implementing the intervention. In particular, staff from evening and weekend shifts would need to be recruited to the PDSGs to ensure coverage across the week. Further issues with the language and structure of the staff handbooks were noted, in particular with respect to readability for care assistants and family members.

Participants reported that the purpose of the PDCs and the training methods needed to be clearer. The staff handbooks, which had been designed to provide information about the intervention, and about introducing and embedding change, were felt to be in need of improvement, including the following: be more visually attractive, use simpler language and provide less information.

Based on these findings, we developed the final version of the purpose, role and person specification of PDCs (see Appendix 9). We agreed the key topics to cover in the preparation workshop, using both presentations and interactive exercises. Box 1 presents the topics for the PDC preparation workshop.

BOX 1

Topics for the PDC preparation workshop

Limitations

We intended to provide a 2-day preparation workshop for PDCs. Owing to a diary mix-up with one of the PDCs, we reduced the workshop to 1 day.

Inter-relationship with other parts of the programme

We finalised our approach to recruiting and supporting PDCs and identified the personal characteristics and professional skills required of them. The support to be provided included a preparation workshop, monthly telephone support (with AB, the programme manager) and a website with additional resources for nursing home staff. We tested this implementation support in our feasibility study in WS2, WP1.

Aim

The aim was to explore family members’ perspectives on their involvement in the timely detection of their family members’ changes in health in UK nursing homes. Specifically, we sought to address:

• How are family carers involved in timely detection of changes in their relatives’ health in nursing homes?
• How can family carers be supported to engage in timely detection of their family members’ changes in health?

Methods for data collection

We conducted 14 semistructured interviews with family carers of residents living in 13 different nursing homes (see Appendix 10). This allowed us to obtain in-depth information on their perceived and preferred role. All interviewees were adult children and lived near the nursing home. We recruited family members who were regularly involved with their relative. We used telephone interviews to gather data from family members who were unable to attend a face-to-face interview.

In addition, we finalised drafts of the following:

• a handbook on the intervention and its implementation for the PDCs
• a handbook about the intervention and its implementation for care home owners and managers
• a workbook on implementation for the PDSGs.

Method for data analysis

Interview data were transcribed verbatim and analysed using thematic analysis.⁶⁷

Any limitations

We were unable to identify family members who lived further away from the care home, despite advertising nationally. We had hoped to include these, as they provide an additional perspective on family involvement.

Key findings

Families were involved in the timely detection of changes in health in three key ways:

1. noticing signs of changes in health
2. informing care staff about what they noticed
3. educating care staff about their family members’ changes in health and how they manifest.

Families suggested that they could be supported to detect early changes in health by developing effective working practices with care staff.⁶⁶

Inter-relation with other parts of the programme

Family involvement was examined in the feasibility study in WS2, WP1. The intention was for care staff to establish how best to work with family members who would like to be involved in the intervention, recording preferences in each resident’s care record, as well as explaining the purpose and application of the S&W.

Five components of the complex intervention

Implementation support

Implementation support included asking nursing home managers to engage in a change management programme, which included:

• identifying two PDCs
• establishing a PDSG to support the work of the PDCs in introducing and embedding the intervention tools.

The study team provided training for the PDCs’ role. We provided two implementation support handbooks:

1. for care home staff (for managers and PDCs)
2. for staff and PDSG members.

The handbooks were to be used in the nursing home to help staff to understand the intervention and support its implementation. The handbooks offer background information on some of the approaches to change used in this project, promote an understanding of how the intervention can be implemented in the differing contexts of each home, facilitate and improve the learning of others in the nursing home, help teams learn and act alongside the people for whom they care, maximise opportunities for all team members to enhance their leadership capabilities, and offer information for residents and their family carers to help them become active participants in developing practice in their care homes.