I work part-time as a community occupational therapist (OT), working with service users, including those living in care homes, to assess and implement interventions that promote participation and independence in meaningful activity. Interventions may include rehabilitation activities, moving and handling guidance, and equipment provision or recommendation. When working with those living in care homes, I will discuss and agree on the intervention with the resident and their carers, give a demonstration, provide written information, and document the recommendations in their medical records. However, a quick return to the status quo is frustratingly common. This seems to be more of an issue when working with people living in care homes than with those living in their own home.
I am now also working part-time on the DACHA study, reviewing research conducted in care homes to identify any emerging patterns and possible guidance for future studies. The studies suggest that the setting poses a similar challenge for researchers as for visiting health care professionals. The studies for review are process evaluations of complex interventions in care homes, and most explore why interventions that may have proved effective in other community or acute settings are either less effective or have neutral findings when conducted in this setting (Edwards and Huguchi, 2018; Ellard et al., 2014; Siddiqi et al.2016). These research interventions appear to be developed and shared with interested staff and residents, but not taken up over time
The findings capture how the heterogenous and multifaceted nature of the care home context can affect the study’s outcomes if not properly accounted for. Many of the reported difficulties arise either when the researchers tried to control multiple contextual variables, or when they assumed a one-size-fits-all approach (Desveux et al., 2019; Holle et al., 2019; Rycroft Malone et al., 2018; Zwijsen et al., 2014). The studies that were able to adjust their intervention to meet the needs of the individual care home reported this as a strength and not something that compromised the trial study design (Desveux et al., 2017; Masterson-Algar et al., 2014).
This work has challenged my clinical practice. As an OT, I am trained to consider how an individual’s skills, routine, motivation and environment impact on their occupational engagement (Kielhofner, 2008). I deliver person-centred care by exploring each of these areas with service users and determining whether adjustments can be made. However, the review findings have made me question whether I too can be at risk of making assumptions or generalisations about what is and isn’t possible in the care home context. I now recognise that unless I have an understanding of the care home’s routine, staff skillset, motivation, workload, and the impact of its particular physical environment, it will be difficult to implement effective interventions for its residents. This approach is likely to be demanding and complex but fits into the holistic approach to care that is championed by occupational therapy, and, according to the research, will be ultimately rewarding. The findings from the DACHA review of care home study process evaluations therefore have important implications for both therapy and research.
Desveaux, L., Halko, R., Marani, H., Feldman, S., and Ivers, N. M. (2019) ‘Importance of Team Functioning as a Target of Quality Improvement Initiatives in Nursing Homes: A Qualitative Process Evaluation’, The Journal of continuing education in the health professions, 39(1), pp. 21–28.
Edwards, N. C., and Smith Higuchi, K. (2018) ‘Process Evaluation of a Participatory, Multimodal Intervention to Improve Evidence-Based Care in Long-Term Care Settings’, Worldviews Evidence Based Nursing, 15(5), pp. 361-367.
Ellard, D. R., Thorogood, M., Underwood, M., Seale, C., and Taylor, S.J. (2014) ‘Whole home exercise intervention for depression in older care home residents (the OPERA study): a process evaluation’, BMC Medicine, 12(1).
Holle, D., Müller-Widmer, R., Reuther, S., Rosier-Segschneider, U., Graf, R., Roes, M., and Halek, M. (2019) ‘Process evaluation of the context, reach and recruitment of participants and delivery of dementia-specific case conferences (WELCOME-IdA) in nursing homes (FallDem): a mixed-methods study’, Trials, 20(45).
Kielhofner, G. (2008) ‘The environment and human occupation’, in Kielhofner, G. (eds.) Model of Human Occupation: Theory and Application. Baltimore, MD: Lippincott, Williams and Wilkins, pp. 85– 100.
Masterson-Algar, P., Burton, C. R., Rycroft-Malone, J., Sackley, C.M., and Walker, M.F. (2014) ‘Towards a programme theory for fidelity in the evaluation of complex interventions’, Journal of Evaluation in Clinical Practice, 20(4), pp. 445-452.
Rycroft-Malone, J., Seers, K., Eldh, A. C., Cox, K., Crichton, N., Harvey, G., Hawkes, C., Kitson, A., McCormack, B., McMullan, C., Mockford, C., Niessen, T., Slater, P., Titchen, A., van der Zijpp, T., and Wallin, L. (2018) ‘A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: an exemplar’, Implementation Science, 13(138).
Siddiqi, N., Cheater, F., Collinson. M., Farrin, A., Forster, A., George, D., Godfrey, M., Graham, E., Harrison, J., Heaven, A., Heudtlass, P., Hulme, C., Meads, D., North, C, Sturrock, A. and Young, J. (2016) ‘The PiTSTOP study: a feasibility cluster randomized trial of delirium prevention in care homes for older people’, Age and Ageing, 45(5), pp. 652-661.
Zwijsen, S. A., Smalbrugge, M., Eefsting, J. A., Gerritsen, D. L., Hertogh, C. M., and Pot, A.M. (2014) ‘Grip on challenging behavior: process evaluation of the implementation of a care program, Trials, 15(302).
Funding Acknowledgement and Disclaimer
This study/project is funded by the National Institute for Health Research (NIHR) Health Service Research and Delivery programme (HS&DR NIHR127234) and supported by the NIHR Applied Research Collaboration (ARC) East of England.
The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.