Person-centred care

Although the concept of ‘person-centred’ care is ubiquitous in UK health and social care policy discourse as synonymous with care quality, there is no consensus on its meaning either in policy¹³⁴ or in research,^162,163 so it is difficult to determine what it might look like in practice. Common dimensions of ‘person-centredness’ include care that is individualised, caring and enabling.¹⁶⁴ Although these components are not exhaustive, they are helpful for our purposes in characterising person-centredness in a CH practice context.

Drawing on observation and interviews, we defined ‘individualised care’ as care that was based on staff having meaningful knowledge of the person (biographical, current preferences and needs); ‘caring’ as reflected in a style of communication that was respectful, warm and responsive to residents’ expressed emotion; and ‘enabling’ as care that involved providing assistance such that a person’s level of competence and confidence was enhanced and independent action was supported. These features were interconnected.

We found that, in the majority of homes at baseline (n = 9), staff demonstrated meaningful knowledge of residents, which was reflected in their encounters with them:

I sit in a chair in between two residents, Betty (smiling and alert) and Peter (who is dozing) . . . we talk for a while about Betty’s family . . . local places to visit, and what she liked to do when she was younger . . . and coming into the home . . . Betty became distressed after saying this with tears in her eyes and I was concerned that my question had upset her. I apologised . . . she replied ‘Oh no, I get like this, I have days like these’. Tina, a carer nearby, remarks to Betty ‘we have our good and bad days, don’t we Betty? And today is one of them bad days.’ Betty agrees with Tina and then thanks her for helping her in her room this morning.

CH9, fieldnote 1035

Engaging with residents in a personally meaningful way was also used to encourage and support residents to take part in leisure activities:

Pat is asleep in a double chair curled up. Two residents are dozing in lounge chairs, sat either side of Pat. Eileen swaps activities so that residents are now using polystyrene sticks to hit a balloon backwards and forwards to her as she throws it towards them and calls out their name. Eileen gives the residents lots of encouragement, e.g. ‘you are doing so well’, ‘come on, keep it going’, and the residents, on the whole, appear to be enjoying the activity. Fred asks every so often ‘Can I just go and talk to somebody?’ Eileen tells him to hang on 5 minutes. She engages Fred in a brief conversation about where he rode his bicycle and asks Maisie if she used to play rounders at school as she is very good at throwing. Eileen often tries to get the residents engaged in a dialogue about their past and their skills, and I think that they enjoy this interaction (smiling, answering back, although it is not always understandable to me).

CH12, fieldnote 1105

In three homes, personally meaningful knowledge of residents was less evident, because of either high staff turnover or poor staffing, such that encounters were predominantly focused on the task, with little or no attention on the resident as a person:

I notice two carers using a hoist. At first I thought that they were putting it away because I could not see from where I was seated the residents who sat in this area, and because the carers were talking over the hoist to each other . . . As the hoist was raised, I see a female resident sat in it. One carer remarks to her ‘don’t be so grumpy’. The resident’s facial expression to me was one of distress. The carers continue to talk amongst themselves whilst lowering the woman into a chair. They then move the hoist out of the lounge area . . .

CH3, fieldnote 1510

In most homes and among most staff, communication with residents was warm, respectful and responsive. In some homes, we observed specific incidents involving individual staff in which the style of communication did not take account of residents’ expressed emotions, especially those with a cognitive impairment. In a couple of homes with a high proportion of residents with dementia who had poor verbal ability, communication practices reflected awareness of and sensitivity to observational cues and individuals’ expressed emotion:

Ted is uttering something that I cannot understand. His voice gets louder and he moves his upper body erratically, as if in distress. Carrie comes back into the room and goes immediately to him. She sits next to him, placing her hand on his and asks in a soothing, gentle tone if he is alright. Ted replies ‘no’ and says something else which I cannot hear. Carrie gets up and returns a few moments later with a beaker full of juice. Ted thanks her and gulps down the entire contents. He then sits back into his chair, more relaxed. Carrie leaves when Ted appears to have calmed down . . . Ten minutes later, there is shouting and distress from Ted again. Carrie comes in and goes to him straight away, gently touching his arm . . . Ted relaxes back into the chair and the quietness in the room returns.

CH1, fieldnote 1341

Care homes were more variable in their practice in providing assistance to residents. Six homes adopted a consistently enabling approach in respect of most tasks of daily living. This involved balancing risk and resident choice, and putting strategies in place to manage risk. In a conversation with the PE researcher, a 90-year-old resident, George, recounted how he had walked to the polling station to vote in the recent parliamentary election and often took the bus into the local town. The manager drew on George’s experience in one of the workshops to convey their enabling approach:

George is physically frail and at risk of falling but he’s able to understand the risks involved. We’ve done a risk assessment and taken steps to reduce the impact of a fall (protective clothing). Some staff are nervous about it but we want to support him in keeping going.

CH2 manager

Although the extent to which enabling was pursued in this example was unusual, it illustrates features of the care processes involved in the approach: supporting resident action and ensuring that potential risks are actively managed.

In a further four homes, practice with regard to enabling was inconsistent between staff and/or practice was enabling in some tasks but not others. For example, some staff provided support and encouragement to residents with mobility difficulties to take some steps in transferring between their chair and wheelchair, whereas others did not; in some homes, individual drinks were given to residents with an accompanying snack directly into their hands or on a table, whereas, in others, residents were encouraged to add milk and sugar themselves, and to lean over and choose a snack from a proffered box/plate. In two homes, practice overall was characterised as ‘care done to’ as opposed to ‘enabling’. In one of them (CH3), although the level of physical dependency of residents was very high, a hoist was used routinely to transfer people who required the support of two carers (around half of residents). Staff acknowledged that this was what was expected of them and was ‘normal’ practice, even though some residents were capable, with encouragement, of walking a few steps.

Flexibility of routines and practices

All homes adopted some flexibility with regard to some aspects of day-to-day routines. Typically, residents were enabled to get up and dressed at a time of their choosing and have breakfast in their room or in the dining room. For those who were dependent on carer support to wash and dress, the degree of flexibility was constrained by staff availability. Similarly, residents chose the time they went to bed, subject to similar constraints.

The main meals of the day (lunch and evening meal) were, in all homes, provided at set times (12.00–12.30 and 16.30–17.30) and were to be taken in the dining room or a person’s own room. There was generally a permissive approach to residents staying in their own rooms during the day if they wished, although some homes actively encouraged residents to socialise with others in the communal spaces or to come out of their rooms to take part in organised social and leisure activities. In all homes, relatives and friends of residents were welcomed. In most homes, there were one or two people who spent time in the home with their relative on most days, providing practical assistance at mealtimes, conversing or reading aloud, playing games or doing crosswords. They also interacted with and kept an eye out for other residents.

More variability existed between homes in the extent to which residents could get a hot drink between set times: in some, this occurred routinely as epitomising the ‘homely’ environment staff espoused to create; in others, residents would be asked to wait until the designated time. A small number of homes enabled residents who were deemed able to get a drink from the kitchen. There were several where residents moved freely between spaces, including between floors. In others, there was little movement from lounge areas beyond that relating to regenerative activities (eating, toileting), which not only reinforced the time spent sedentary, but was a factor that contributed to minimal resident-to-resident interaction. All homes had access to outdoor spaces, most of which were attractively landscaped. With a couple of exceptions, residents were able to access these only if accompanied by a member of the care staff.

Across all homes, a notable feature was how most residents’ daily lives were lived within the spatial boundary of the CH. In two homes, some residents were regularly (weekly) taken to a local community centre/club; in others, organised trips out occurred as special events or celebrations (a birthday treat with a visit to a pub or cafe); in yet others, relatives might take a resident out. The narrow spatial organisation of CH life also contributed to the narrowness of residents’ social lives.

Social, leisure and stimulating activities

Homes varied considerably in the opportunities available for engagement in social, leisure and stimulating activities. Not all homes had dedicated AOs in post, and even those that did (three of five intervention homes and five of seven control homes) varied in the level of resource available. Thus, AOs mostly worked part time (a couple of full week days, or mornings or afternoons on weekdays only). Three of these eight homes had varied and extensive short-interval (weekly) and medium-interval (monthly) organised activities for mental and physical stimulation (e.g. quizzes, games, discussions, creative writing, crafts, baking, indoor bowling, chair exercises) and special events at longer intervals internal and external to the home (e.g. external entertainers, mini-bus outings, theatre/cinema trips). The rest had a narrower range of organised activities [games, weekly trip out to a community centre for dancing and a drink, music and special events (external entertainers)]. Of those homes without an AO, there were spontaneous short-interval events (e.g. music and singalong, games, chair exercises) and organised medium-interval events using external resources (e.g. Music for Health, exercise class) or CH staff (e.g. film nights, reminiscence). In all homes, care staff engaged in some one-to-one pampering work (e.g. manicure) and there was access to a hairdresser/barber. This pattern of variation existed across intervention and control homes. Although the home with the most extensive and varied programme of social, leisure and stimulating activities was a control home, it was rivalled in its range of stimulating and creative activities for a ‘healthy mind’ by one of the intervention homes.

Understanding the significance of movement in daily life routines

Overall, most care managers conveyed a general belief that ‘exercise’ and keeping ‘active’ was a ‘good thing’ to maintain residents’ well-being and to facilitate their engagement in social life. This awareness was a factor in their interest in taking part in the study. By contrast, thinking about everyday life activities through the lens of movement was not common.

Engagement in MoveMore

The implementation team included a range of stakeholders: senior home staff (manager and deputy manager), catering manager, AO, team leader, care worker, housekeeper and chef. Although the deputy manager assumed the work of intervention ‘driver’ and the AO took responsibility for ensuring completion of the documentation, other members of the team played a part in the implementation work, as either active facilitators (the manager) or contributors within their own spheres (the chef conducted observations, reflecting on and developing action plans in relation to them with the catering manager). The workshop venue was a room in the organisation’s head office, in a separate location to the CH. This offered space for uninterrupted discussion.

From the outset, there was an understanding that, for change to occur, communication and engagement of the wider staff group was necessary. Thus, the deputy manager involved care staff outside the team in carrying out observations and opening up discussion on ideas for facilitating movement. In this respect, observation, reflection and action-planning were conceived of as iterative and linked processes brought together through discussion between individual members of the team, including in the workshops and in established forums, such as handovers and staff meetings.

Installation and initial implementation

From a care environment perspective, there was acknowledgement in the first workshop and in conversations with staff that the home had hitherto been very good at promoting activities for a ‘healthy’ mind. However, movement, and its benefits for well-being, had not been at the forefront of staff awareness. There was much talk about the changing resident profile – physical frailty at point of admission and increasing cognitive impairment – that required re-evaluation of how they delivered care. Even so, it also seemed that the dominance in discussion of the challenges of residents living with dementia was at odds with the actual proportion of residents with moderate/severe dementia in the home.

In common with other study homes, prior to taking part in MoveMore, senior staff had begun to consider movement in the context of their resident profile and the physical environment. Their hope regarding participation was that movement could be incorporated into care routines, notwithstanding the cultural, normative and environmental obstacles they would encounter.

Between the first and second workshop, a period of 2 weeks, team members conducted observations and reflections within their different spheres. There was a sense from senior staff that the creation of momentum was critical to moving forward. By the second workshop, team members had completed six observations and reflections. These embraced observations of individual residents in the main home selected on account of their poor mobility, use of communal space in the dementia unit and its effect on resident movement, and the breakfast routine in the dining room. A learning point emphasised by participants was that, if residents were to be encouraged to move more, the strategies adopted had to be meaningful to them.

Among participants, their experiences of observing practice had enabled them to ‘see’ things not only as staff going about their work, but also how the environment might be felt from the perspective of residents with varying interests and needs. Furthermore, individual, joint and team reflections on their observations provided the head room to consider creative ways to explore ‘out of the box’ solutions and how they might go about making change happen. Action-planning in this respect was seen to flow from the observation and reflective process, with the additional element of establishing the ‘how-to’ steps to secure desired changes. The artist translated ‘challenges’ and ‘solutions’ (observations, reflections and action plans) into visual images. These were subsequently presented as pictures and displayed in the communal and staff spaces as a means of communication, and as an aide memoire to foreground movement in routine practice.

Two issues in particular were reinforced in this second workshop and picked up by the team: action plans might not work and so should be open to review (both the objective of the action plan and the steps to achieve it); and an aspect of the process should include how to engage the wider group of staff in the work. Preparatory to the third workshop, team members were to develop, write up and try out action plans based on their observations.

Fieldwork in the period between the second and third workshops revealed that work on translating observations into action plans was proceeding and several action plans relating to individual residents were being tried out. These involved negotiation with the resident and, when possible, support and encouragement was sought from family members. As a means of engaging care staff beyond the team, the MoveMore lead had also elicited care staff in conducting observations, freeing up time from usual routines by helping out with care tasks. Nine observations and reflections were completed by care staff in different settings, at different times, focusing on individual residents and small groups. Discussing observations with individuals subsequently had generated lots of ideas on how movement could be enabled and these were being written up by the MoveMore lead as action plans.

From initial implementation to full adoption

The third workshop considered action plans developed by the team, drawing out key learning points. What might appear initially as relatively simple changes could have unanticipated consequences requiring further action. For example, expanding ‘meaningful activity’ for residents, a goal of the AO, involved shifting the focus of her work a little from group to one-on-one activity. This involved the development of further action plans relating to supporting care workers to take on some group activities. PE observation at 6 months noted that a new care staff member was confidently leading a group activity with nine residents: a quiz, followed by music and enthusiastic rhythmic swaying and foot-tapping. The example in Box 7 illustrates an action plan that was incorporated as part of the home routine.

BOX 7

Care home 5: example of action plan and action

A significant development from the work was an initiative of the MoveMore lead and catering manager aimed at routinising the process of change as part of the care culture. In outline, this involved training all staff in MoveMore principles and processes, including observation and action-planning, which would be reviewed in staff’s quarterly supervision sessions.

From innovation towards sustainability

Over the subsequent 6 months, action plans were reviewed in routine forums, for example those relating to individual residents were incorporated in their care plans, specific organisational changes became part of the care culture, and the process of embedding movement through training and supervision had begun. At the 9-month time point, one training session had been delivered to staff in varied care roles across the home and others were planned. Enacting such systemic change had involved considerable work over a 6-month period, which was more sustained and less immediate in its impact than some of the practice changes for individual residents.

For senior managers and staff involved in implementation, the MoveMore intervention had resulted in movement being placed at the forefront of CH culture, and in systems and processes being put in place (training and supervision) to embed this change in routine care delivery.

Engagement in MoveMore

Care home 4 was characterised as a ‘full implementer’, albeit delayed. Similar to CH5, initial steps in programme installation were embraced by the manager with enthusiasm. The first workshop was organised within 2.5 weeks of the programme induction meeting and the second workshop within 3 weeks of the first. There was then a hiatus (14 weeks) before the third workshop took place, meaning that MoveMore installation was completed only shortly before the 6-month data collection point. This was a consequence of contextual factors with direct impact on the organisational and care environment in which the intervention was delivered and which, in turn, affected the priority attached to the work of MoveMore implementation. In the following narrative, we draw out the temporal sequence of events and our interpretations of them to inform understanding of the implementation process.

At the induction meeting, preparatory to installation, the manager had indicated that implementation would be pursued by a ‘loose’ group of staff. Although she would take responsibility for pushing forward the change process, participation in the workshops would depend on who was working in the home on the day.

Installation and initial implementation

The first workshop allayed some of the research facilitator’s concerns about leadership and commitment: taking part were the manager, one of two deputies, a senior care worker, a care assistant and a cook. The venue (dining room off the main lounge) meant that proceedings were subject to interruptions. These included residents making their way into the dining room and adjoining kitchen, and participants rushing off to deal with a crisis event: episodes which were revelatory of residents’ ease of access to spaces within and across the home, and the absence of uninterrupted headspace for staff to reflect and plan.

Conveyed in this first workshop was a staff group committed to improving the care of residents. From the manager’s perspective, the main challenge was that many of the staff, although very caring in their relationships and encounters with residents, were resistant to changes in established work routines and very task focused. Many had worked for many years in the home (both deputies had been employed there for > 20 years, working their way up from being care assistants). The manager was relatively new, being < 3 years in post. This picture of an established staff group was also evidenced in the annual staff turnover rate (11% – one of the lowest of all participating homes).

The value of resident movement, conveyed by the physiotherapist, found resonance among participants. They also indicated that increasing movement would require changing staff culture and practice so as to motivate residents. Similar to CH5 staff, the team considered that movement had to be incorporated as part of a resident’s daily life (i.e. that it was purposeful and meaningful).

Participants, especially the deputy and team leader, were keen to try out the observation tool. In accordance with the significance she attached to engaging the wider staff team, the manager proposed to discuss the study in the next staff meeting.

Between the first and second workshop, five observations were completed by individuals within the implementation group and by other care staff. These formed the basis for reflection and discussion of action plans in the second workshop. Continuity of participation was provided by the deputy manager (Marion) and the second deputy (Cheryl); a carer also took part. The manager was occupied elsewhere, and the senior carer and care worker who had previously attended were not on shift. The artist was unable to attend.

Observations embraced individual residents with poor mobility, the pattern of movement in the main lounge and the reluctance of residents to move from ‘established’ seats to take part in activities elsewhere. The process of observation was perceived as valuable: ‘seeing’ and reflecting on positive and negative features. As in CH5, discussion on observations and reflections appeared to ‘free up’ thinking about changes that could be made. For example, observation of how specific staff encouraged a resident to improve mobility with assistance, and its effect on the resident’s mood and in reducing isolation, offered a mirror for other staff and a basis for action-planning to change practice. The extended periods of sedentary time spent by residents in the main lounge directed attention to the seating arrangements and established resident routines. Chairs were organised in two parallel lines facing each other, discouraging interaction between residents. Several residents had ‘their own’ seats and were reluctant to move from the lounge for fear of losing them, limiting participation in activities not centred on this space. Ideas for challenging routines included reconfiguring the seating in the main lounge and introducing ‘chair-swopping’: periods during which residents were asked to ‘swop’ seats. Ideas were to be written up as action plans and tried out in anticipation of the third workshop, to include the artist. With 1 month before the 3-month data collection point, programme installation appeared on track for completion within or around 3 months, as in CH5. Box 8 provides an example of action for an individual resident.

BOX 8

Care home 4: example of observation to action plan and action

Informal discussion with a member of the implementation team during the 3-month data collection point suggested that work to develop and test action plans was being pursued. For example, chairs in the lounge were reconfigured to facilitate ‘chair-swopping’. This was successful in initiating interaction between different residents and in generating short bursts of movement, also documented in the PE fieldnotes. The refusal of one resident to move, after reluctantly agreeing initially, involved further negotiation with her, including enlisting her relative’s support to persist with the initiative. This resulted in some revisions: ‘swopping’ at some times and on some days only, as long as it was achieving the objective of enhancing interaction and movement. The experience had also directed attention on other initiatives to address the same goals. Despite progress, written action plans were not available. It seemed timely to organise the third workshop to examine the change process and how it was being captured.

Momentum falters

Over the subsequent weeks, it proved difficult to arrange a time for the third workshop; a support meeting, involving both research facilitators, was organised. Although the manager indicated interest in continuing with the intervention, there was a palpable sense of loss of energy, as well as frustration with some staff who persisted in the view that a colleague was ‘slacking’ by spending time in conversation with a resident. The recent CQC inspection (within weeks of the second workshop) and assessment (‘requires improvement’ in documenting systems and processes) had also affected staff morale and prioritised work in response to the inspection by senior staff.

A third workshop was planned to include the artist – now 14 weeks after the second workshop, and between the 3- and 6-month data collection points. Staff appeared unprepared for the workshop and the manager was preoccupied. The deputy (Marion) had taken on the work of steering MoveMore, but was not on shift. There was the possibility that we had reached the nadir of the intervention in the home.

Resuming momentum

The desultory response was somewhat belied by location of the MoveMore documentation with several newly completed observations and action plans, suggesting that work was under way. Discussion with the second deputy manager (Cheryl) indicated that progress was being made in each of the areas that were the subjects of action plans. The artist created images capturing aspects of the work that had been described for the team to use in engaging the wider group of staff with MoveMore, which were subsequently displayed prominently in the communal spaces.

Full adoption

From around the fifth month of the intervention, the deputy manager (Marion) emerged as the de facto MoveMore steer, facilitated by support from the manager. In addition to the focus on reducing sedentary time, there were two features of the implementation process that extended the programme’s reach to the wider staff group: (1) new care staff were enlisted in conducting observations, including two night staff; and (2) the requirement on the home from the CQC inspection to develop more detailed resident care plans was used by senior staff, led by Marion, as a vehicle to incorporate action plans around movement for individual residents. This drew on staff observations and direct work with residents to elicit preferences to inform plans. The work involved was time-consuming and slow, but was regarded as setting the ground for incorporating observation and action-planning into CH routines. By the end of the intervention, there were specific examples from conversations with residents that action plans for individuals were in place; for example, a resident with very limited movement was being supported daily by care staff to practise exercises developed by the physiotherapist.

As care plans became the means through which action plans were pursued, a communication book was initiated for staff to record and sign the action and progress, reviewed on a monthly basis by the manager.

Interviews with senior staff and carers at the 6- and 9-month time points were positive about the impact of MoveMore. The journey was described as very difficult (some staff were resistant to change, but the team was persevering), but the benefits for residents were seen as worthwhile. For staff, the process of change had altered their approach:

You’re always rushing about and you don’t, sort of, take stock of what is really going on. But . . . now I do sit back and take stock; who’s doing what, when and where and what times and . . . it’s just what I do.

Senior member of staff, CH4

Other changes from what was ‘UC’ at the outset of the study were in place or being planned in the home: an opportunity for a collaborative project with an external organisation for a dancer to work with residents was taken up, and a group providing physical and mental stimulation through exercise and games was engaged to come in on a monthly basis. These ‘external’ events were regarded as additional to but not a substitute for the day-to-day work of care staff with residents in supporting movement.

Innovation and towards sustainability

A primary route through which MoveMore was adopted – incorporating movement as part of the care-planning process and as a specific aspect of individual resident’s care plans – was also a strategy for routinising movement in CH routines. At the home level, initiatives were also being pursued. Individual care staff were encouraged to take forward ideas for regular ‘events’ with residents, for example advocating and securing funding for a karaoke machine to enable them to enhance movement through music, purchase of a broader range of materials to work with residents and new garden furniture in conjunction with the development of the external space as a safe environment for residents to spend outdoors.

Engagement in MoveMore

There was a lengthy gap (10 weeks) between randomisation and the first workshop, which took place within 1 month of the 3-month data collection stage. The difficulties experienced prefaced a change in the process of engaging homes in MoveMore implementation.

The first workshop was attended by the deputy manager (and designated implementation lead), team leader, senior carer, a member of the domestic staff and a relative: all staff had worked in the home for between 8 and > 20 years. In addition to the two research facilitators, the physiotherapist also took part. Key challenges in increasing movement in the home from the perspective of staff were twofold: the level of physical frailty and cognitive impairment among their permanent residents, and the multiple and complex demands on staff in working with diverse groups of people (i.e. permanent residents, those receiving intermediate care and those on short-term respite). In terms of their residents, they saw the benefit of PA in terms of mental well-being, and were enthusiastic about opportunities for increasing movement in residents’ daily life routines and for trying out the observation tool.

Installation extended in time

Following the first workshop, there was a further time lag in getting the second workshop organised. In part, this was caused by the fact that the 3-month data collection for the trial was due which would put demands on the home. In addition, the implementation lead was preoccupied with preparing documentation for their CQC inspection visit. A support meeting involving the research facilitators 6 weeks after the first workshop elicited continuing commitment to engaging in MoveMore implementation and frustration at being unable to prioritise working on it. Both the implementation lead and the care team leader had undertaken observations, but were concerned as to whether or not they ‘had done it right.’ The research facilitators reiterated the purpose of observation as taking time out from routine work to ‘look at’ an aspect of practice through the lens of movement and to reflect on whether or not, and in what ways, there was potential to increase movement. It was a tool to explore current practice as a launching pad to identify aspects for improvement. It was for them to decide what was right. We discussed a couple of observations both had done and assured them that they provided a basis for considering next steps as envisaged in the programme.

The second workshop occurred 1 month later, involving the implementation lead, the care team leader and a senior carer. Four observations had been completed relating to general features of practice: reinforcing an enablement approach in illness recovery, extending meaningful activities that incorporated movement (use of outdoor space), providing opportunities for interaction between residents, and developing action plans in respect of an individual resident around engagement in meaningful activities. Following discussion of the action-planning process, they considered that they had enough to work on to expand their reflections into action plans and try them out prior to the next workshop. An additional point was to involve the newly appointed AO as part of the implementation team. Although involvement of the artist in the second workshop to capture discussion on action plans was conceived of as part of delivery at this point, it was not possible to synchronise mutual availability. It was agreed that this would occur at the following workshop.

The third workshop, with the artist, occurred just over 4 weeks after the second workshop and shortly after the 6-month data collection. It was intended to review the action plans developed and action arising from them. Days before it was due to happen, the implementation lead communicated that he had been under ongoing pressure relating to both the audits being carried out in preparation for the CQC inspection and taking on managerial responsibilities on account of sickness among senior staff. It was agreed, however, that the workshop would go ahead, attended by the de facto implementation team – team leader, care team leader and senior carer.

Initial implementation

Although action plans had not been formally written up, action in relation to several of the ideas discussed had been pursued (Box 9). The team leader recounted using the staff meeting, the usual forum in which to discuss improvements in practice, to generate discussion about encouraging movement. Team members talked in detail about how the work of the AO was offering new leisure and social activities for residents. As the implementation team had not met, it was less clear whether it viewed the work of the AO as one vehicle through which MoveMore was being pursued or as the expression of it. Nevertheless, it was also evident that organisational difficulties in the home – imminence of the CQC inspection, demands on the lead and team leader to take on management tasks in absence of the manager – were a constraint on time. The artist captured the discussion on action plans and action for development as a poster. This was subsequently displayed in prominent communal areas, giving rise to speculation among residents as to who was who on the poster!

BOX 9

Care home 1: example of action – a resident’s experience

From fieldwork, conversations and interviews with members of the implementation team and AO over the last 3 months of the study, individual members had sought to pursue specific initiatives on movement in the prolonged absence of the team lead on account of illness. Issues arising from the CQC inspection assessment (‘requires improvement’ – relating to documentation of processes and procedures, and providing more detailed care plans) diverted the attention of senior staff in responding to them (in contrast to CH4, where the solution to the same problem was to mobilise MoveMore to address it).

Pursuing change systematically did not occur, or did so in fits and starts only. Aspects of implementation, observation and reflection on what needed to change and the steps necessary to make it happen were perceived as valuable. Although the concept of action-planning was understood (unlike in the ‘failed implementer’ site; see ‘Failed’ implementer), pursuit lacked momentum. In the absence of a clear steer, beliefs about the worth of the intervention were not translated into consistent action to make it happen. Alignment and integration of movement in context of the routine work of care and the provision of social and leisure activities was still a work in progress, as care staff and the AO negotiated mutually supportive working relationships that acknowledged each other’s perspective.

Conversations and interviews with the MoveMore lead and team members, including the AO, at the conclusion of the study reported that change had occurred as a consequence of their engagement in MoveMore. They also expressed regret that they ‘had not [had] more time to spend with it and to become more organised around it’, but felt constrained by internal and external factors affecting the home. It came at the ‘wrong’ time: it was ‘untimely’. Nevertheless, they expressed interest in taking the work forward in the future.

Engagement in MoveMore

Care home 3 was a ‘partial implementer’ and, similar to CH1, the process of installing MoveMore extended in time. The CH manager was enthusiastic about taking part in the research: on many occasions during baseline and pre randomisation, the manager asked that the researcher ‘put in a good word’ so that the home would be selected for the intervention, despite explanations about the nature of randomisation. As considered in Person-centred care, the pattern of ‘UC’ in this home presented some challenges.

The first workshop was organised to take place within 3 weeks of the introductory meeting with the CH manager, using a common script: components of the programme, implementation team driving the change, workshops, manual and supporting resources. The workshop was cancelled on the day: the manager was on compassionate leave and, although the deputy indicated that it would go ahead, it became evident to the fieldworker in the home that no work had been done for it. It was also considered unlikely that staff would be released: the home was short-staffed and several senior staff members from the care organisation’s head office were at the home carrying out a review, preparatory to the CQC inspection.

After several attempts, the first workshop was held 8 weeks after the introductory meeting. Participants included the CH manager (identified as the MoveMore lead), receptionist, a senior carer (team leader), carer and both part-time AOs (between them they covered one full-time post; one of them also worked as a bank carer). Discussion about current practice and challenges experienced was slow to get going and staff were hesitant about taking part. One of the care staff and AOs presented the challenges in terms of residents becoming very quickly institutionalised, expecting that staff would care for them, focusing the discussion on work that should be undertaken at the point of admission. The manager acknowledged the challenges, but considered that improvements were possible. Presentation of MoveMore and the use of observation as a tool to see things differently was picked up by a team leader and one of the AOs; there was, however, no sense of collective engagement around a common purpose and there was the absence of a driver to move it forward. A date for the second workshop was set and agreed with the manager for 3 weeks after the first.

A week before the second workshop, the manager commented to the PE researcher who was observing in the home: ‘We have another training session, do you know why?’. The significance of the question was revealed at the workshop. Of the seven participants, none had attended the first workshop. With the exception of a nurse, all were care workers. Their expectation was that they had come to a training event on how to increase residents’ movement. The facilitators agreed to proceed with the programme with the content of the first workshop.

Care staff conveyed the physical demands of the work: most residents were very dependent and needed hoisting to move between wheelchair and chair. Further probing suggested that ‘need’ was more ambiguous: some residents could transfer from wheelchair to armchair on some days and not on other days; others required the assistance of two carers to transfer and they were required to use the hoist; for yet others, lack of time meant that it was quicker and easier to use the hoist. With a complement of four care staff, a ‘floater’ on the morning shift and four in the afternoon, a team leader and a nurse, tasks relating to the ‘bodywork’ of care¹⁶⁶ were seen to dominate. Although highlighting how organisational and cultural factors might be implicated in work practices, care staff were unconvinced that the programme could work in their home. Neither could they conceive of having the time or space to observe practice. The nurse present disagreed: it was possible for care and nursing staff to carve out time to conduct observations and take part in the intervention.

Installation: one step forward, two steps back

As the 3-month data collection began, a research facilitator organised a meeting with senior staff in the home (the manager and deputy). One observation had been carried out by the team leader after the first workshop, but the manager and deputy were not aware of any further developments nor had they undertaken any work to pursue it. Following negotiation between the team leader, the manager and the deputy, it was agreed that the team leader would take on the work of MoveMore lead and would pursue the programme with support from the research facilitator.

Following a further delay of around 8 weeks, and within weeks of the 6-month data collection point, the second of the three workshops focusing on completed observations and implications for change occurred, involving the team leader and two care workers, together with the research facilitator. Two new observations had been carried out at different time points: one in the early morning, which opened up the possibility of residents doing more for themselves with enabling support, and one in the early evening, which highlighted the paucity of stimulating activities. Although the first appeared more of a ‘fit’ with the objective of MoveMore, it was not pursued: support from the wider team was not considered feasible. Work pressures on care staff had increased as a consequence of the departure of one of the two AOs, and were exacerbated by care staff vacancies. The second observation, over the following months, was developed as an action plan to introduce a stimulating leisure event in the early evening. This was enacted as a musical event and ‘movie night’ during which these care staff were on shift. Regarded as successful in that the events facilitated interaction between some participating residents, the team found it difficult to consider how they could proceed further forward. Passive support from the CH manager had enabled them to pursue one-off initiatives, yet team members considered that the lack of active support from senior managers overall undermined what they sought to do, reinforcing the already tense relationships with senior staff.

Initial implementation

The team had proceeded through the stage of installation and initial MoveMore implementation: participation in the workshops, and taking the observation, action-planning and review process back into their work environment. However, the limited temporal and spatial spheres of engagement (action relating to one-off events and within their own work arena only) and lack of focus on movement per se, suggests that full adoption had not occurred.

Interviews with senior staff at the conclusion of the study revealed a mixed picture, both in their assessment of the outcome of the intervention and their expectations of it. The CH manager considered that the intervention had made a positive difference in encouraging residents to move, with the team leader actively encouraging staff to work in a more enabling way with residents. The expectation was that this would have been translated into training for the wider group of staff. The deputy manager was more critical: senior staff had provided these workers with the time and space to participate in the MoveMore implementation, but they had not shared their experience with the wider team:

I want everybody to get involved, but because they [implementation team] are the only ones [it was explained to], they didn’t manage to share with them . . . everybody needs to have knowledge about what they’re doing so that when they’re not there, I can instruct [staff] . . . ‘can you do your REACH training?’ . . . my hopes were that you will help us to find the solution to those residents who’s unable to move properly because . . . the programme is about mobility.

Deputy Manager, CH3

The departure of the team leader signified a natural end to MoveMore. Service change was moving in a different direction with the introduction of external entertainers and exercise classes.

Engagement in MoveMore

This was the first home in which the introductory one-to-one meeting occurred post randomisation, based on the experience with the first intervention home (CH1). Nevertheless, there was a delay in starting. Between the introductory meeting with the CH manager (MoveMore lead) and the first workshop, there was a gap of 6 weeks. The first planned workshop was intended to occur jointly with CH1 (both were in the same locality). Participation of CH2 was cancelled on the day by the manager, citing staffing difficulties, and a further date was negotiated. There were no further joint initiatives between these homes during the study and no other homes expressed interest in working together.

Five staff took part in the first workshop: manager/owner, one of two deputy managers and three care staff, of whom two had worked in the home for several years and one was new to the post. In terms of seniority and experience, the team spanned ‘top-down’ and ‘bottom-up’ participation. As well as the two facilitators, the research team also included the physiotherapist.

First steps in installation

Initial presentation of the programme generated some scepticism: care staff suggested that they were already doing as much as they could to facilitate resident PA. The manager interjected that he had specifically involved them in the implementation team because they understood the value of movement, but that this was not necessarily shared by the wider staff group. This opened up discussion of the challenges of enhancing movement perceived to be located at two levels: the reluctance of residents to move and the limitations of time on carers. Encouraging residents to move more required time, which was difficult to envisage within the constraints of the tasks required of them.

Discussion of the concept underpinning MoveMore, the discomfort people of any age experience from prolonged inactivity and the possibility of small changes making a difference, generated multiple ideas as to what could be done differently; they appeared open to trying out observation as a means of establishing goals for change. There were concerns expressed by one of the carers that other care staff might perceive the ‘observer’ as shirking and ‘not pulling their weight’. How the MoveMore programme was conveyed to the staff team by senior staff was seen as critical.

Fieldwork conducted following the workshop established that 10 observations had been carried out and written up by care staff in the implementation team within a little over 3 weeks following the workshop. This meant that the first stage of programme installation coincided with the start of the 3-month data collection. There were difficulties in securing a firm date from the implementation lead, in part because of the preparatory work required for an imminent CQC inspection and the demands of REACH data collection within the home. The second workshop finally took place nearly 9 weeks after the first, several weeks after the CQC inspection (although prior to the published report), and involved the artist.

There was continuity of participation of members of the implementation team. Those who had conducted observations considered the process useful: as care workers, their focus was on completing the task in hand. Tacit knowledge (‘what I’ve always done because it works’) based on experience shaped practice, but opportunities to stand back and reflect on what was happening through the prism of ‘movement’ provided a different perspective. It was evident, however, that the team had not shared their observations with each other, and shifting from the content of what they had ‘seen’ to what it might pose for working differently was more difficult for some participants. Others, as experienced in the ‘full implementer’ homes, were more skilled at thinking about options for movement flowing from observations. Overall, the discussion, moving between what was observed and action to effect movement, resulted in agreement on a division of labour on who would pursue what: ideas relating to individual residents were to be developed by care staff, and those about home-level action were to be pursued by the team lead. It was noted by the team lead that their recent appointment of an AO (during the 3-month data collection period) to work weekday mornings would enable carers to be less pressured in getting through their morning regenerative work (getting residents up, dressed, toileted, breakfasted and settled), a particularly busy time. The artist captured the discussion in sketches for development as a poster, which was picked up with enthusiasm by participants. A time frame for the third workshop was agreed to enable action on plans to be tried out and for progress to be reviewed.

Process evaluation, observation and conversations in the home following on from the workshop suggested that the implementation team was planning to meet ‘to get our thinking together about what to do next’. Concurrently, the new AO was pursuing quizzes and board games, particularly in the middle lounge, building on and supporting interaction between residents. Her focus was getting to know residents a little and acquiring knowledge of their interests and preferences. Residents in the top lounge remained largely seated and dozing, occasionally taking note when something happened, for example the ‘home’ dog running about. Music featured strongly in routine and organised events: different types of music shaped the atmosphere in different spaces. A monthly ‘Music for Health’ event was popular as a source of stimulation, interaction and movement.

When the third workshop took place as planned, team members seemed unprepared. The impression was that the salience of MoveMore in context of their day-to-day work had been lost. Members of the care team had got together only briefly prior to the workshop and concluded that they lacked understanding as to how to develop action plans, nor did they recollect their completed observations. The research facilitators drew on the images produced by the artist as an aide memoire and revisited the action-planning and review process with concrete examples. A further workshop to review progress was offered, accepted and then not pursued by the implementation lead. No further work on MoveMore occurred; the poster developed from the artist’s images was not displayed in the home.

MoveMore ‘washes out’¹⁴³ prior to initial implementation

Although a conjuncture of external and internal factors contributed to implementation failure, deeper issues relating to leadership and the coherence of the intervention as worthwhile to invest in were implicated. These included temporal features of the organisational context and the coherence of MoveMore to staff as a means of effecting change.