Participative action-planning approach (action groups)
Action groups were established in each of the four homes, consisting of manager(s), care staff, residents, relatives/friends and a member of the research team, who acted as a facilitator. Twenty-nine individuals consented to participate in the action groups (nine residents, 18 staff and two relatives/friends of residents). We recognised that residents with the cognitive ability and willingness to participate may not be representative of the client group in that home; therefore, we sought innovative ways to involve the wider resident group.
Having developed a prototype for how an intervention might be delivered and a preliminary outline of issues that should be addressed (see ), an action research cycle of service improvement was employed to develop the intervention and engage staff and residents directly in the process of how to make change happen.65
The action groups aimed to follow the provisional intervention developed in WS3. The purpose was to create a dialogue between researchers and these stakeholders about implementation strategies to increase PA/reduce sedentary time of residents, to try these strategies with staff and residents, and to review barriers to and opportunities for implementation in the real-life context of CHs that varied in terms of their resident profile and care environment.
Information about the importance of movement and some of our initial ideas were presented by a member of the research team and discussed with the group. Each action group was tasked with considering the current pattern of movement of residents, both in respect of the routines of daily living and during the leisure periods, and with exploring ways, through action plans, of increasing the PA/movement undertaken by residents in their CHs. At each action group meeting, progress in achieving action plans was reviewed through input/dialogue between members of the group. Barriers and solutions were identified, changes/refinements were made, depending on the progress achieved, and new action plans were developed to take the process of change forward through successive improvement cycles. The researchers also fed the group relevant data pertinent to contributing to the service improvement process. This included examples from observation, ‘ideas’ from the resource pack and emerging data systematically collected on the process of action-planning and the effects on staff and residents. In this way, we built up an ‘ideas bank’ of ‘what works, how and for whom’ in the real-life context of the home.
The proceedings of the action groups were, with participants’ permission, recorded and transcribed verbatim for analysis. Researchers also carried out observation of the process of implementation as it proceeded and contributed to the action cycle. Ethnographic observation and informant conversations between action group meetings built up a picture of the CH environment and the possibilities for change, and examined how and in what ways the strategies that were tried out affected residents.
Results of participative action-planning approach (action groups)
Action groups were successfully convened in all four homes, but sustaining engagement in the intervention implementation process as planned was challenging. The researchers successfully maintained engagement with the CHs, recorded group activities and collated observational data, as planned.
However, within the homes, there were practical difficulties in sustaining the action groups and maintaining interest in implementing change. These barriers included organisational turmoil, high rates of staff turnover, time constraints and a lack of senior management interest in supporting the process. On occasion, there were tensions between group members: between care staff and managers, between residents and care staff, and between researchers and care staff.
Challenge: there appeared to be a gap between our explanation of what the research was about and CH managers hearing what the study involved. The concept of increasing movement both at the level of daily life routines and in the leisure spaces appeared difficult for those working in the homes to understand; instead, movement was perceived of more in terms of PA/physical exercise.
Response: to ensure that, in the feasibility trial, the engagement in the study is not a one-off agreement but a sustained process of negotiation and to be very explicit about the focus of the research.
Challenge: on an organisational level, the difficulties of implementing change in CHs were highlighted. These included rapid unexpected changes of staff (and, in once case, ownership of the home), staff perceptions of the distinctive role of the activity co-ordinator and the work generated by Care Quality Commission (CQC) inspections.
Response: to consider what would support and drive the intervention and to ensure that implementation is sustained.
Response: it became clear in this WS that a more detailed implementation plan was required to optimise embedding the intervention in the CHs. Consideration was given to whether or not the intervention should be more prescriptive. This would not, however, take account of the very different circumstances and contexts of each CH, a key feature of the research in all of the CHs in the programme thus far. However, we did consider that there was an important difference between a more explicit process of implementation (what should happen and when in terms of making change) and the content of the changes, which should be home specific.
Response: training (interactive structured workshops, advice from experts, demonstration of strategies) could be incorporated into the implementation plan.
Challenge: a significant issue that emerged in three of the homes was the lack of engagement from care staff in activities around movement, as care staff perceived their role as primarily about the delivery of care. There appeared to be a divide between ‘care’ and ‘activities’, whereby movement is conceived of as part of ‘activities’ and is the realm of the staff charged with responsibility for ‘activities’ (i.e. the activity co-ordinator). This divide was perceived as a more active antagonism between some care staff and the activity co-ordinator in one of the CHs.
Response: to reconsider if we had clearly expressed in the presentation of the programme/intervention that the work of increasing movement embraces all staff. The materials and implementation process were amended to ensure that this key concept was fully captured.
Challenge: in two CHs, difficulties in knowing when to ‘push’ residents were expressed. Residents’ choices should be respected, so if they chose to remain in their rooms/have meals in their rooms this choice should be respected. There was also a lack of knowledge about how far to push residents, given their ill health.
Response: an experienced CH physiotherapist assisted with implementation of the intervention in the feasibility trial, specifically by providing a short introduction on the importance of movement.
Challenge: in the individual homes, some staff in the action groups were able to recognise that residents were sedentary, but in other homes there was a reluctance to acknowledge that any change could be achieved and staff were quite defensive. There was a perception from managers and carers that they were doing all they could to promote movement when they have enough time to do so.
Response: an important factor in engaging staff in a programme of change is to encourage them to take a close look at/reflect on what they currently do. In their CH, are residents encouraged to move? All residents? Some residents? In what aspects of CH life (self-care, walking about, organised leisure activities)? What works well? What does not work? And for whom? Staff need to be convinced that, in the context of their ‘home’, what is involved is more than what they currently do, and the value of the change is worth the work involved in making it happen. Difficulty in getting staff to recognise the potential of increasing PA prompted the further development of a short observational tool that staff were encouraged to complete. This enabled them to explore current practice and consider what might be done to effect change.
Supporting staff to take a step back enables them to have a different perspective, challenging taken-for-granted ideas and practices. The observational tool was designed to combine simple, short observation with critical appraisal (what actually happens), and follow quickly to actions. For example, staff members might spend 10 minutes observing, at a particular time of the day, particular residents and particular activities (personal care and daily life routines, moving about, individual and collective leisure activities). They could then more proactively engage in identifying problems/barriers and consider whether or not and how the activities are modifiable.
Facilitators: action groups and the ongoing engagement with the CHs during this WS provided a great opportunity to gain insight into staff perspectives. This enabled us to establish what modifications were needed in the content and delivery to improve the implementation and acceptability of the intervention and embed it into practice, as well as establishing what works, for whom, in what contexts.
The action groups were successful in identifying a number of actions, including rearranging chairs in communal areas to facilitate interaction, incorporating short walks into care routines and encouraging residents to participate in domestic tasks. Interventions for individual residents were undertaken and music was used to prompt PA/movement.
Response: These ideas were incorporated into the ‘ideas’ bank of the intervention.
Success: engagement with a local artist was particularly successful. Residents described their daily life to the artist and he depicted this in drawings (). This succeeded in engaging residents with communication difficulties (e.g. from dementia, stroke) and stimulated lively discussion. The immediate outputs were displayed in the CHs and served as prompts to increase movement of residents and staff. The input of the artist became an integral component of the intervention.
Artist’s drawings. Pictures developed through ‘movement’ discussions with staff and residents, facilitated by a researcher and in collaboration with a local artist, Tom Bailey, at one of the Workstream 4 homes.
Accessible summaries of the key findings were produced and fed back to staff and residents in each home (see examples in Report Supplementary Materials 7 and 8).
Through this careful iterative work (led by co-applicant Mary Godfrey), we successfully produced a defined intervention to be implemented to enhance the PA of residents in CHs, which was still focused on the four key themes identified [see Workstream 3: development of an intervention to enhance physical activity and appropriate methods of implementation (e.g. training materials) through a process of intervention mapping].
