Written evidence submitted by Researchers from Edinburgh Napier University and University of Edinburgh, aligned to the Care Home Innovation Partnership in Lothian, Scotland (WBR0095)
We are a group of researchers aligned to the Care Home Innovation Partnership in Lothian Scotland. We work closely with the care home workforce researching a range of issues. These include: palliative and end of life care; the development of a Care Home Data Platform in Scotland; relationship centred care with people with advance dementia in care homes; and developing the research capacity and readiness of care homes in Scotland through the Enabling Research In Care Homes network. Four of our recent projects, two funded through the Chief Scientist Office Rapid Research in COVID programme, speak directly to the enquiry questions highlighted below and hence our reason for submitting evidence.
Lucy Johnston, MSc, Research Fellow, Edinburgh Napier University. Background in Social Policy and expertise in conducting health and social care service evaluations and research studies.
Dr Jo Hockley OBE, PhD, RN, Senior Research Fellow, Usher Institute, University of Edinburgh. Expertise as a Consultant Nurse for Care Homes and developing palliative and end of life care in care homes in the UK, supporting and educating care home staff.
Dr Julie Watson, PhD, RN, Senior Research Fellow, Department of Nursing Studies, University of Edinburgh. Expertise in care home research in palliative and end of life care, dementia care, supporting care home staff and care home nursing in the pre-registration nursing curriculum.
Dr Cari Malcolm, PhD, RN, Lecturer in Nursing, Edinburgh Napier University. Expertise in resilience in the care home workforce.
Dr Susan Shenkin, MD, Geriatrician and Reader, University of Edinburgh. Expertise in geriatric medicine and building capacity for research in care homes.
What has the impact of the COVID-19 pandemic been on resilience, levels of workforce stress, and burnout across the NHS and social care sectors?
1.1 In care homes for older people, the majority of direct personal and social care is provided to residents by staff who are not registered nurses which we refer to here as frontline care workers (FCWs).
1.2 Whilst FCWs work alongside registered nurses and other health and social care practitioners, they have different training, skills and duties compared to registered nurses.
1.3 Moreover, in contrast to registered nurses, FCWs are less likely to have connections to professional bodies or organisations and thus lower levels of awareness of how to identify and access evidence-based information on care practices and how best to support their wellbeing at work.
1.4 FCWs may be at greater risk of burnout given a number of factors including, but not limited to: long and unsocial working hours, low pay and status, and the increasingly demanding physical and emotional nature of their work (VonDras et al. 2009; Health Foundation 2017; Dreher et al. 2018).
1.5 FCWs have a higher rate of turnover than other members of social care workforce (Donoghue et al. 2010; Rosen et al. 2011).
1.6 The impact of the ongoing COVID-19 pandemic on care homes has intensified the need to ensure the care home workforce is supported to build resilience, avoid burnout and remain in their roles delivering quality and compassionate care to older people.
1.7 Evidence for best practice in supporting the resilience and retention specifically of frontline care workers in care homes is extremely limited, of variable quality and lacks generalisability. At present, it is dominated by cross-sectional studies mostly from out with the UK. The small number of intervention studies are inconclusive.
1.8 Multiple factors are suggested as being associated with best practice in supporting resilience and retention - Culture of Care; Content of Work; Connectedness with Colleagues; Characteristics and Competencies of Care Home Leaders and Caring during a Crisis.
1.9 Key guidance for supporting health and social care has emphasised the importance of promoting awareness of wellbeing resources available to staff, and where to access additional support when needed (WHO, 2020; British Geriatrics Society, 2020; University College London, 2020).
Building on the above context, researchers at Edinburgh Napier University and University of Edinburgh received funding from the Chief Scientist (Scotland) Rapid Research in COVID-19 programme, to examine how the wellbeing and psychological and mental health of frontline care workers (FCW) in care homes for older people has been supported during COVID-19 (February to July 2020). We also undertook a scoping review of the published literature. The key findings of these studies are as follows:
2.1 There is a wealth of wellbeing resources available online and more were made available during the pandemic. However, for FCWs, identifying relevant, high quality resources can be difficult and time consuming and online resources were reported as not being a main source of support.
2.2 Online wellbeing resources need to be tailored and targeted to FCWs in care homes to bridge the identified delivery and uptake gaps.
2.3 There is a need to better understand how best to assist care homes to facilitate uptake of tailored and targeted resources by FCWs.
2.4 Care homes, families, residents and staff benefited greatly from morale boosting creative activities and staff groups and individuals ‘going the extra mile’. However this is not sustainable and internal and external resources for wellbeing must be replenished so staff are able to continue to provide effective and compassionate care to residents and look after their own health and wellbeing.
2.5 The benefits of supportive communication within the home for staff wellbeing have been identified. They can take many formats and be either formal (for example end of shift huddles/checklists and supervision) or informal (for example peer support and an open door culture).
2.6 This work reinforces that the culture, leadership and supervision practice of each care home is key to staff wellbeing.
2.7 RECOMMENDATION: Work to develop wider quality improvement and training initiatives for practice-based preventative psychological wellbeing must be embedded within homes.
2.8 Care home managers wellbeing and practice development is aided by sharing their learning and experiences with peers.
2.9 RECOMMENDATION: Support Groups and networks for care home managers should be established, facilitated and resourced.
2.10 RECOMMENDATION: High quality, adequately powered, co-designed intervention studies, that address the fundamentally human and interpersonal nature of the resilience and retention of frontline care workers in care homes are required (Johnston et al 2020)
COVID-19 Trauma Guidance suggests opportunities for structured, time-limited discussions about challenging experiences should be offered. The same researchers undertook a second study funded by the CSO Rapid Research in COVID-19 (June 2020- October 2020) to pilot a system of Online Supportive Conversations and Reflections (OSCaRs). These sessions were delivered by palliative care specialists to support care home (CH) staff in relation to death and dying. The key insights from this body of work are as follows:
3.1. The sessions identified that where there were a large number of deaths in the care homes, often combined with a large number of staff who were absent due to COVID-19 or shielding.
3.2. Although a wide range of staff including physiotherapists and activities teams were able to pull together, this still resulted in a high level of disruption of care at the end of life. Usual practices to support a resident who was dying, such as sitting with them, holding their hand, talking to them and the families, etc were no longer possible, leading to emotional distress for staff.
3.3. Some deaths were unexpected, while other residents had dreadful breathlessness which was very frightening for CH staff especially with no on-site nurses and no general practitioners visiting care homes.
3.4. Staff were really pleased when some residents who were Covid-19 positive ‘pulled through’, however the 3-month isolation had had a big psycho-social and physical toll on residents especially those with dementia.
3.5. Overall, the emotional strain on care home staff has been enormous – and there is a huge need to understand this especially in care homes without on-site nurses – with no real healthcare professional support. We fear these staff will find the second wave of the pandemic extremely difficult to cope with.
3.6. Staff taking part in the online briefing sessions reported feeling ‘lifted’; staff who had previously been ‘misunderstood’ felt more accepted, and staff spoke openly in front of one another, including staff who would not usually interact during their daily work.
3.7. The sessions provided valuable learning about death/dying from experienced healthcare professionals.
3.8. RECOMMENDATION: We strongly recommend that ongoing support of sessions that both support and advance practice-based learning in palliative and end of life care are maintained for Care Home staff including front-line care workers, nurses and ancillary staff.
3.9. 57% of care home residents die within a year of admission and education on palliative and end of life care, which incorporates care of self and psychological well-being, will help foster resilience and prevent burnout.
3.10. Valuable initiatives, such as OSCaRS, that link practice-based learning and psychological wellbeing cannot be provided as a short term response to COVID-19. The real benefits for staff and residents will come from working collaboratively with care homes to embed recovery for their staff and empower longer-term resilience.
How resilient was the NHS and social care workforce under pre-COVID-19 operating conditions, and how might that resilience be strengthened in the future?
To what extent are there sufficient numbers of NHS and social care professionals in training for service and resilience planning? On what basis are decisions made about the supply and demand for professionals in training?
The background and recommendations in this section draw on a project funded by the University of Edinburgh exploring student nurses’ attitudes to care home nursing and the co-creation of curricular content on care home nursing in the pre-registration nursing curriculum (Watson et al 2020).
4.1. Pre-COVID, the resilience of the social care workforce in care homes has been precarious for some time. A Scottish survey (Scottish Care 2015) found an overall nurse vacancy level of 28% in the independent CH sector with 98% of CH providers having difficulty filling nursing posts, and vacant posts taking on average 7 months to fill.
4.2. Retention of nurses was also a significant issue with a 30% turnover rate.
4.3. This is placing many care home providers in an increasingly precarious position which risks the quality and continuity of care of frail, older people and sustainability of services (Scottish Care 2015).
4.4. The problem has become more acute as the care home population has increasingly complex care needs relating to the combination of age (85+), multi-morbidity, cognitive impairment, limited mobility, polypharmacy and the need for palliative care (Gordon et al 2014).
4.5. This complexity requires specialist knowledge, but opportunities for professional development for the Care Home workforce are currently limited (Spilsbury et al 2015).
4.6. RECOMMENDATION: Career pathways and professional development opportunities for nurses to develop as leaders in the social care sector are urgently needed.
4.7. Appropriate support and valuing of nurses in the care home setting, the integration of such care within the wider health care system and optimal models of health care delivery, are all fundamental prerequisites for future care home nursing (Gordon et al 2018, Pijl-Zieber et al 2018).
4.8. Research has shown that care home nurses themselves see their role as stigmatised, partly due to perceptions of the general public, and from within the nursing profession, that their work lacks clinical sophistication (Thompson et al 2016).
4.9. There is international recognition of the need for well-educated nurses to meet the complex needs in the social care sector including care homes (Spilsbury et al 2015, Kiljunen et al 2016). This necessitates the embedding of older people nursing in settings such as care homes in responsive curricula and education programmes, including practice placements, and there are examples of this occurring internationally e.g. Finland (Kiljunen et al 2019), Australia (Loffler et al 2018), the Netherlands (Snoeren et 2016) and in the UK (Tiplady et al 2018).
4.10. However, in the UK, student nurses in Higher Education Institutions (HEI) receive the majority of their clinical placement learning in acute care nursing (Spilsbury et al 2015) with little emphasis on older people nursing settings.
4.11. RECOMMENDATION: Explicit inclusion of care home nursing in pre-registration nurse education (Watson et al 2020) as well as challenging prevalent professional and public misconceptions about role of CH Staff and residents’ experiences.
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