Successfully working with care homes

Researchers in Wales recently completed phase one of the Probiotics for Antibiotic Associated Diarrhoea (PAAD) study within care homes. This case study details their experience and provides advice to others wishing to conduct research in a residential Care home or nursing home setting.

Background

The aim of the PAAD study was to provide incidence data on antibiotic associated diarrhoea (AAD) in elderly people and to evaluate care homes as a setting for conducting complex studies. Phase one involved 270 residents across nine care homes that consented to take part in a 12-month prospective observation study to collect information on the frequency and type of antibiotics prescribed and the frequency, seriousness and cause of any AAD. Before starting the study the researchers sought advice from a Care home expert to ensure that the data collection required was already part of their care plan routines; the study required Care home staff to record details of the type and dose of antibiotics prescribed, to collect stool samples and maintain daily stool chart records from the time the antibiotic was prescribed and eight weeks after treatment completion.

Donna Duncan RD, Senior Project Manager, said: “We are seeing an effect on what happens to residents on an on-going basis which impacts on the quality of care staff provide.”

Challenges

• Staff confidence – initially staff felt overwhelmed by the tasks required of them, as not all understood the protocol.

• Workload – ensuring the study fit into the daily schedules of staff was difficult. Care home managers felt it added extra work to staff’s already busy workloads and staff felt the study burdened them with more paperwork.

• Inconsistent handovers – the shift patterns of Care home staff meant that not all handover information was communicated, affecting the quality of the data collected.

• Limited storage space – there was little space for equipment or any secure storage area for study documents within the care homes.

• Lack of experience – none of the nine care homes had any experience of participating in research and therefore required additional support to set up the study.

Approach

The PAAD study team worked closely with care home staff and was involved in the following activities:

1. Approaching the care homes: The team made a list of all the care homes within the region and contacted them over the telephone. A follow-up letter confirmed a meeting and briefly outlined the study. Nine care homes agreed to take part.

2. Engaging the care home managers: The trial lead met with each care home manager to discuss what the study involved, outline what was required from them and their staff and detail the benefits the care home and residents were likely to receive. At following meetings they discussed the best approach for conducting the study, logistics within the care home and how to involve staff, residents and families.

3. Seeking consent: Focus groups were held with family members, consultees, staff and GPs to discuss the study and obtain consent. Consultees acted on behalf of residents that lacked capacity to understand the study. All participants were consented within 6 weeks.

4. Staff engagement: During the first 6 weeks staff received training on how to set up the necessary processes and documentation. Staff also met the study team and chief investigators to discuss site issues and how to improve recruitment or resolve the quality of data.

5. Communication: Team meetings, newsletters and posters were used to provide study updates to site staff, residents and their relatives.

6. Incentives: The study financially rewarded each care home and provided individual incentives to staff via training certificates, mentions in work newsletters, thank you letters and gift vouchers.

7. Support: As work progressed the study team took responsibility for completing the paperwork as the care home staff were unable to fit it into their workloads. The team also increased the frequency of visits to monitor data collection and build closer relationships with the care staff.

Lessons learned

The team found care homes to be very different to other environments where clinical research is carried out. Some of the challenges encountered by the research staff were due to the study team’s lack of understanding about the care home environment.

The study team has learned better ways of undertaking research in care homes and would provide the following advice for anyone conducting research in such environments:

• At the study design stage, consult an ‘expert’ with experience of working in a care home

• Allow plenty of time to approach care homes, set up sites, recruit residents and run the study

• Bolster confidence, engagement and professional development of staff throughout the study

• Ensure equipment and processes are easy for staff to complete and ready; so as to not add to their workload

• Identify study research leads among those working all shift patterns

• Provide training to staff several times; 2-3 weeks before the start of the study, before recruitment and then once the study begins. Provide training continuously after that point with specific staff groups to identify what is required of them

• Embed your own staff in the care home to collect information from residents and carry out any sampling.

Outcome

The study recruited on time and to target with 100% recruitment at the end of June 2011. Since conducting the study each care home has continued to apply what the study introduced and has recognised it as good practice. The PAAD study team enjoyed working with each home and found it very rewarding to see them integrating evidence based practice into routine care.

For more information

Contact: Dr Arun Acharjya (Trial Manager) & Donna Duncan (Senior Project Manager)

Email: AcharjyaA@cardiff.ac.uk or donna.duncan@wales.nhs.uk