“We should see her like part of the team”: an investigation into care home staff’s experiences of being part of an RCT of a complex psychosocial intervention

Abstract

Objectives: To contribute to improvements in the design and delivery of intervention research in care homes by adopting a collaborative approach that listens to the experiences of care home staff who had participated in a clinical trial aimed at optimising and evaluating a psychosocial intervention package for people with dementia.

Methods: Qualitative study involving focus group discussions (FGDs) involving 41 staff across 6 care homes with the UK. Inductive thematic analysis was used to identify themes and interpret the data.

Results: Three overarching themes emerged as influential: Recognising preparedness; working together and learning more than expected. The findings highlighted the need to be attentive in addressing staff expectations, the value of sustained relationships and recognition of good practice. The FGDs also identified areas of unanticipated learning that staff and managers adopted.

Conclusions: The FGDs showed the importance of considering the overall experience of care home staff who are involved in research and the importance of valuing the skills and experience they hold through positive affirmation. There are often unanticipated consequences of research involvement both on staff practice and on relationships which if promoted could help sustain effective ways of working together.

Keywords:

• Psychosocial intervention
• staff
• qualitative
• care homes

Introduction

Despite a growing call for increased co-production of services and research with people with dementia and recognition of the value of involving end users of research (INVOLVE, 2014), there is a paucity of research which directly incorporates the understanding and views of care staff in designing and developing research questions. More frequently psychosocial and care research has engaged with care staff as recipients of training and as participants in the delivery of the interventions under evaluation, proxy raters of residents’ outcome measures or the subjects of research themselves. Recently published research goals from leading dementia clinicians and researchers in the UK assert that engagement must extend to the dementia workforce if we are to address practical problems and develop credible solutions (Pickett et al., 2018).

Despite the growing evidence base for nonpharmacological interventions (Brodaty & Arasaratnam, 2012; Bird, Anderson, MacPherson & Blair, 2016) they continue to be poorly implemented in health and care settings (Fossey et al., 2014). Research findings recognise that staff interactions and behaviour have a crucial impact on people with dementia’s experience (Kitwood, 1997; Ward, Vass, Aggarwal, Garfield, & Cybyk, 2008, Brooker & Latham, 2015) and are key to delivering interventions in clinical trials and everyday practice. The complexity of undertaking research in care home settings has been well documented, for example, in terms of cultural factors, recruitment and intervention fidelity (Luff, Ferreira & Meyer, 2011, Vernooij-Dassen & Moniz Cooke, 2014). It is therefore important to understand how staff experience being part of research in the variety of ways that they are contributing. Evidence suggests that poor communication and organisational constraints can act as a barrier to implementation (Kaasalainen et al., 2010). To support research involvement with care homes, the NIHR ENRICH toolkit was developed to provide guidance for researchers and care homes about how to work alongside each other and information for homes and families considering research participation. This study sought to elicit the experiences of staff who participated in a project in which the ENRICH principles of doing research “with” rather “to” care home staff had been followed, in order to use staff views of this in clinical practice to inform further research.

In the randomised controlled trial (RCT) Well-being and Health for people with dementia living in care homes (WHELD) (Ballard et al., 2017), care staff were seen as an essential part of the research process. Prior to the study care staff were involved in identifying the key factors in implementing psychosocial care in their settings, which contributed to the development of the intervention process (Lawrence, Fossey, Ballard, Ferreira & Murray, 2016). Once the RCT began the research team used principles outlined on the ENRICH website to guide their interactions in setting up and conducting the research. Staff contributed in a number of ways in the project including supporting the collection of information about themselves, the residents and their work setting, participating in training and working with residents directly and taking part in the interventions in line with study protocols. This project took place following staff’s involvement in the RCT in order to understand their perspectives, with hindsight of being involved in the research so that the findings could be incorporated into the design and delivery of a larger follow-up RCT (Ballard et al., 2018)

Methods

Design

This study was part of a cluster-randomised trial involving 16 care homes in London, Oxfordshire and Buckinghamshire. The homes were identified randomly from all care homes rated as “adequate” or “better” on the UK Care Quality Commission (CQC) register. Each home received training and weekly support from a research therapist to develop their person centred care practice and a random allocation of either person centred care alone or between one and three other key interventions with established efficacy: review of antipsychotic medication, social interaction and pleasant events and exercise (Ballard et al., 2016, 2017). Implementation and outcomes are reported in Ballard et al. (2016, 2017) and used to guide intervention development in a subsequent study (Ballard et al., 2018). At the end of the study care home staff were invited to participate in a focus group to discuss their experiences of participating in the research process and of the different elements of the research interventions. Two homes were recruited purposefully from each of the three recruiting centres to provide variation in terms of type of intervention, type of care home and care home ownership. The characteristics of the homes are shown in Table 1.

Table 1. Summary of details of care homes participating in focus groups.

Care homes (n = 6)	Size of care homes
	Small (fewer than 30 residents)	Medium (30–64 residents)	Large (65 or more residents)
No. of care homes	0	5	1
Registration
	Care only	Care with nursing
No. of care homes	3	3
Size of organisation
	Small (fewer than 3 homes	Medium (3–10 homes)	Large (more than 10 homes)
No. of care homes	2	2	2
Business type owner
	Not for profit	For profit	Registered charity	Local authority
No. of care homes	1	3	0	2
Type of Intervention
	Person-centred Care	Exercise	Social interaction and pleasant activities	Review of antipsychotic medication
No. of care homes	6	3	2	2
Number of intervention elements
	1	2	3	4
No. of care homes	1	2	2	0

Participants

Purposive sampling was conducted in discussion with the care home manager so that the perspectives of staff in a variety of roles and with a range of experience of the research process within the home could be obtained. Invitation letters were sent to potential participants, which emphasised that the focus group discussion (FGD) was an opportunity for staff to share their experiences of taking part in a research project, which could in turn influence how a further clinical trial (Ballard et al., 2018) would be delivered, thereby actively shaping the research development process (Barker & Hinton, 1999). Where possible the focus groups consisted of 6–8 members of the care team.

Six focus groups, involving 41 staff, were conducted across six of sixteen care homes within the UK who had participated in a 9 months randomised control trial of psychosocial interventions for people with dementia. Participants included 24 care assistants, 6 senior care assistants, 5 activity therapists, 1 registered nurse, 2 managers and 3 housekeeping staff. They ranged in time spent working at the home from 3 months to 20 years, the median amount of time being 12 staff who had worked in the home for 3–5 years. 41% of staff reported no formal care qualification, 20% had their highest level of national vocational qualification (NVQ) at level 2 and 24% at NVQ level 3.

Data collection

The FGDs aimed to explore staff’s experiences of being involved in a research trial over a 12-month period, which included recruitment and consent, data collection and the 9-month intervention period, and their experience of using psychosocial approaches as defined in the study protocols (Whitaker et al., 2013). The FGDs were carried out approximately one month after follow-up data had been collected and lasted about an hour each. They were conducted by two experienced qualitative researchers from the wider study team (JM, JS), who were not involved in any other data collection or in the intervention delivery, and who aimed to adopt a neutral approach. Views were sought on which elements of the study process were inclusive and successful and the particular intervention activities that had taken place in their setting. The discussions also explored any unhelpful aspects of the process or interventions, the challenges to implementation within the care home and any learning they had developed and intended to take forward as a result of study participation. The topic guide was developed by the study team drawing on learning from their previous qualitative work in this area (Lawrence et al., 2016) which highlighted the importance of care home contextual factors and the experience and perceived value of interventions by care staff. The topic guide was designed to elicit staff’s experiences of participating in all aspects of the research process and was revised iteratively allowing the main issues identified by participants to be explored in depth. Participants were encouraged to articulate both positive and negative views and differences of opinion were sought and expressed. The FGDs were recorded and transcribed verbatim; observations and impressions were noted at the end of each group. Recruitment ceased as few new themes emerged from the later FGDs.

Data analysis

Thematic analysis was undertaken to identify themes and interpret the data (Braun & Clarke, 2006). Four of the authors (JF, LG, IT, JM), who had different roles in the study team, read the transcripts in order to immerse themselves in the data. Multiple coding was conducted on three transcripts initially to allow researchers to identify and discuss any alternative interpretations. Data were separated into meaningful fragments and labelled with codes. The constant comparison method (Glaser, 1978) was used to delineate similarities and differences between the codes and to develop categories and sub-categories. Ideas about themes were recorded in analytical diaries and discussed within the team. The researchers compared their coding strategies and instances of disagreement were discussed until a consensus was reached and an initial coding frame agreed. The researchers then each coded one or two transcripts independently, using the agreed coding framework, which continued to be refined during fortnightly analysis meetings. This led to the development of three key themes: ‘recognising preparedness’; ‘working together’ and ‘learning more than expected’. The accounts provided in the results are anonymised and labelled with a care home code number.

Results

Some staff who attended the FGDs had participated in all the research activities, such as participant recruitment and data collection, as well as the intervention delivery. The FGDs provided an opportunity for them to discuss the whole experience but the focus of discussion in all groups repeatedly returned to the delivery of the research intervention. Those who did talk about their involvement in recruitment and data collection recollected the procedure and their understanding of it in relation to the first theme of “recognising preparedness”.

Recognising preparedness

The FGDs revealed the importance placed on the research team to support and develop care staffs’ level of knowledge and preparedness for the project.

He [the care home manager] tried to explain as much as he could. We just like to nod our head. (Laughs) (Care home 3)

Staff discussed the value of clearly identifying the purpose of the research and its relevance to their practice alongside recognising that staff members have different levels of interest and understanding of what research involves. It was considered important that members of the research team be available to discuss queries as well as provide written explanation where necessary. In both circumstances, recognising and checking there was a shared understanding facilitated engagement and progress. An example of potential confusion was the use of layman’s terminology applied to the research process.

Has it any specific objective to it you know? It’s like because it’s “random”, here and there, you know. (Care Home 5)

Care staffs’ preparedness in terms of their perceptions of involvement with a University also varied from apprehension to a sense of opportunity. There was a strong sense that ‘when you’re doing something new like you hear “study” it’s quite daunting isn’t it?’ (Care Home 2). A small number of the staff noted their contribution in supporting residents to participate in the project.

…‘Because before they came there was a notice on by the floor. Those people come in and interview our residents because they can’t just come and interview residents without our knowledge. (Care Home 3)

The research objective of improving resident care acted as a strong motivator for some staff, but it remained important for staff to be able to express hopes and concerns surrounding the research and to discuss the activities with which they were being asked to engage. Clarity about the expectations of their own practice and the implications for residents were important early issues for the research team to address.

I thought it was a good thing, but you’re always unsure of new things of how it’s going to affect you in the workplace. (Care Home 2)

At first when she said about it, about reminiscing about the memories of the old times Ithought you know, will we be bringing back bad memories for them or would they enjoy it? (Care Home 6)

However, many of the FGD participants felt prepared and motivated to be part of the project because they recognised the potential for learning and for developing new ways of working and solving problems and appreciated the research team’s involvement in supporting them with this.

The first impression I have with it is like there will be somebody who come around and teach us new things, that we did not know before or wasn’t doing and that person would work alongside us to improve where there is not much support. (Care Home 5)

A recurring theme among care staff was the sense of working in an undervalued profession, so taking part in research was regarded as an opportunity to counteract these views by providing evidence of good practice.

I hope this will focus and spread out and when the WHELD finish and whatever [care home name] will be up there! (All laughing) because we work our butt off, each and everybody. (Care Home 5)

Working together in clinical practice

Sustained involvement

By having consistent members of the research team engaged with each home during recruitment, data collection and intervention delivery it enabled relationships with care staff to develop and facilitate close working on the project. As part of this process, staff noted how valuable it was when researchers took time to listen to the difficulties that they experienced carrying out their existing roles and their desire for change, which often aligned with the research aims.

We were looking for something new because a lot of staff having problems having service user to do activity, that’s a major problem with people and dementia in a home, some have interests, some don’t, so we were really interested in getting something for everybody to do (Care Home 5)

This value of on-going involvement was particularly notable in relation to the relationship with the research therapist who supported the intervention. As staff became accustomed to the presence of the research therapist and interest grew.

When she first come yeah and when we see her like once a week or twice a week. We just got used to her coming and it was nice. (Care Home 3)

The sustained nature of the research therapists’ involvement with the homes enabled them to engage directly with the challenges staff faced in their specific clinical practice. This helped staff to feel supported in solving care conundrums and incorporating learning into practice.

She was very patient because like I said at the beginning it was so hard and she was always there you know… and it was a real pleasure and I really learned from her a lot. (Care Home 6)

We threw a couple of individual cases at her and she went away and got us extra ideas and she came back with a lovely book on bathing problems. (Care Home 2)

The sustained involvement of the wider research team over time also enabled them to facilitate engagement of staff that joined the home after the start of the project.

Well I came into in late so I had to catch up on what was going on because I was one of the last ones to come in. (Care Home 5)

Shared perspectives

All groups commented on the research therapists’ ability to demonstrate a willingness to work alongside staff and that they shared the objectives in improving care for the residents.

[I] was trying to get that in to place in the home and I thought it would help back up what I was trying to get the staff to work with residents. (Care Home 2)

I think we don’t feel much concern because the way she introduced herself, since the beginning she led us to understand that she’s not here to intimidate anybody, We should see her like part of the team. (Care Home 3)

Some participants reported that negative attitudes among colleagues had at first created barriers to taking part. However, this was to an extent mitigated once benefits for residents became evident to the wider staff team.

Once they see the residents what they were giving back, and they could see the other side then they just sort of quietened down a bit didn’t they because they could see there is something coming out of this. It’s not just a case of going off (for training). (Care Home 6)

The use of experiential techniques in training which introduced the perspective of the residents was seen to demonstrate the relevance of the research to day-to-day practice and was a highly valued as a method of engagement.

We did practicals, we do stuff like how you feel if you are a resident for example we have… like you are a resident, some of the staff are feeding the yoghurt and they’re putting the cardigan and just putting the wheel chair…Yeah, so it really works whenyou become a resident because you don’t know what especially when you don’t know what you are talking about because some of the staff they’re forcing the wheel chair and talking to some other people. So it’s very scary. (Care Home 4)

Time to carry out the interventions was a significant concern in all groups. Staff recalled that they had felt time pressured to incorporate the activities in the daily programme, yet many also recognised that there had been benefits when that had been achieved.

And as you said doing the one-to-one you know it kind of because sometime it used to be like from eleven to twelve you wonder how you going to, you know, get everything in you have to be doing this, doing that…but now as you said you can do a ten minutes you know with this group, a five minutes with this person talking and stuff like that so yeah, it turns out nice. (Care Home 5)

Respecting the competing demands and varied commitments of staff helped the research team to engage staff with the project.

Because some people who are contracted and they can only do contracted hours, she tried to make sure the contracted hours people were able to be you know… and there was so much flexibility and [researcher therapist] would come you know at our time rather than her time and that’s what helped us didn’t it? (Care Home 1)

In some instances, staff also seemed to empathise with the research therapist and recognised mutual time pressures to follow the study protocols. Where good relationships existed both parties exhibited flexibility to collaborate for perceived residents’ benefit.

Like when [the research therapist] came she said to me “you ready”? I said well I’m not ready yet I said I’ve still got this I still got to toilet them and then you know she must have felt bad because thinking I didn’t want her up there which I did, but I still had all my bits and pieces to do and then she came down and had to do it down like one of these units so that’s how we worked out it at finish. (Care Home 6)

Positive affirmation

The researchers’ respectful approach was key to supporting staff. Whilst it was important that teams addressed areas for improvement and developed new practices in line with the research intervention, care staff also drew satisfaction from reflecting on positive aspects of their care at the outset of the training and during the intervention phase of the study.

We were proud that we didn’t have that many residents [needing medication] anyway, but it’s even given us more that zest for life as we must try and refrain from [prescribing medication] you know. (Care Home 1)

The active appreciation of good work through feedback from the research team was highly valued by care staff and sustained their involvement in the research. It contrasted with the aforementioned general lack of recognition that care staff experienced in their role.

Female 1: [They] don’t recognise people for what they’ve done, because you’re just a carer.

Male 1: Well listen for the WHELD project we did yeah, during the process of the WHELD project the lady who came in was able to recognise the fact that we did a good job.

Female 7: Yeah she did.

Male 1: As far as I’m concerned she recognises what we did, yeah after analysing the sheet she got and the same day her response she appreciated the job we did here, as far as WHELD is concerned. (Care Home 5)

Learning more than expected

In all the FGDs staff spoke about the different things they had learned from their participation in WHELD training and delivering the research intervention. In some cases, this was specific and anticipated knowledge in relation to care practice, which had been outlined as part of the initial invitation to participate in the research. At other times, there was evidence of unexpected learning as staff described changing their attitudes to their work and developments in practice. This emerged in four clear sub themes.

Personal impact of changing practice

Staff not only highlighted the direct positive benefits they observed in residents as they changed the way they related to them, but also the personal benefits that this afforded.

Many highlighted the fun involved in delivering the interventions and developing new ideas, noting that, “Instead of it becoming a chore, it became perhaps a more sort of an activity that gave pleasure” (Care Home 1). Some groups commented on the apparent paradox in which doing more with residents in some ways reduced their workload.

I can work on this unit and then move to the other one, I can call to my neighbour and say you know how this person relates to certain things so when they tell me that person’s habit at last I know to deal with it, so make it easier for them plus myself and you have a smooth day. (Care Home 5)

There was a strong sense of pride in all groups that the research process had supported them to develop new approaches with residents and develop an understanding of how to tailor their care to individuals.

We made a discovery on antipsychotic medication, somebody that had been twenty-four hours dozed out, they got to talk to us now, they are now speaking. (Care Home 3)

Female 3: There’s one lady we’ve got down here and she’s not had a very, very nice life at all, even her childhood wasn’t very nice and then her marriage wasn’t very nice and you can understand why she’s a bit like she is now.

Female 1: (Interrupting) bitter, yeah.

Female 3: Whereas before you might just think oh she’s a bit of a whine she’s always got the hump but now you can see why. (Care Home 6)

Adopting new psychosocial activities inculcated a belief in staff that they were making a difference to resident’s lives, which further engendered a sense of agency and pride in their work.

We’re actually starting a [care home name] choir so we’ve got you know we’re actually asking for volunteers to join the choir and we’re going to have residents in the choir as well [as staff] and we’ve got like you know ideas that we’re gonna go like global so you know… watch out! (Care Home 5)

Team building

Many FGDs commented on how working to change their practice as part of the research intervention created challenges such as a need for additional material resources. Working together as a team and thinking creatively was seen as key to meeting these challenges.

Because I know it will be hard to get the funds to buy this stuff [reminiscence materials], but between all of us you know maybe we collect things. (Care Home 6)

Some of the successes were founded on good relationships with members of the local community, such as the school arranging for pupils to visit. And some were achieved by changing the way they worked together within the home.

…they do tend to… work as a team trying to work things out now, instead of just going ‘oh it must be me’. They’re getting together in the meetings, because we do have staff meetings and things, and saying ‘mmm, we’re having this issue, it’s been recorded, we’ve tried this, any other ideas?’. You know, so, that’s quite nice that people are doing that I think. (Care Home 2)

…we never used to have meetings, you know, to come together to say you know what we can do differently and stuff like that (Care home 5)

Relationship with family

Participation in the research project also affected staff’s relationship with relatives, in particular, fostering trust and communication. A widely held view was that “they [relatives] were so happy too because they know that for us to be asking more, that shows the interest we have in their grandma or mum or whatever” (Care Home 3). Participation in WHELD also generated opportunities for working together with relatives to support residents, for example with the logistics of activities outside of the home. One staff member noted, “Well I take, I tend to take them out, I have a group of volunteers now”. (Care Home 2)

However, consultation with family members was not consistently positive and staff reported feeling disappointed when support was not forthcoming or where they developed activities that residents’ enjoyed, but residents’ family considered unacceptable.

Female 9: One day we polished in the hall, we put nail polish manicure on their nails with her and she liked it, but it in the end the family said no.

Female 5: (Interrupting) The family is never happy.

Female 9: That’s it they’re never happy so you have to take it off, so we can’t decide for them.

Female 5: But she liked it.

Male 1: But is it right, the family to come and say they don’t like it? (Care Home 5)

Unanticipated changes to structures and organisation of work

Whilst there was an expectation that specific interpersonal skills would be developed as part of the WHELD training, participants also recognised a number of unanticipated ways in which the research project processes had shaped the way they continued to work. There were a number of ways this learning “is something that she’s left, like a legacy if you like”. (Care Home 1). Participation in the project impacted upon the way information was routinely gathered through the adoption of research methods and materials. Research record keeping influenced wider practice and enabled some homes to recognise how to record their achievements in other areas of work.

And I must say the staff are much, much better at documenting since WHELD for, activity and things because they knew that was important for you to monitor results and things. But it actually is good for us because it shows they, we do often we’re very good at doing things but not actually documenting it. (Care Home 2)

Participants also attributed changes in the way information was shared, reflected upon and actioned to their involvement in the study.

We never used to have meetings, you know, to come together to say you know what we can do differently and stuff like that. (Care Home 5)

But I think the way we work now you allocated, you allocate [a] member of staff who’s going to be doing activities and every day it changes so all the staff get that moment with the residents and you allocate staff to doing tasks, so things are getting done as well as our residents getting that special time. (Care Home 2)

Participants identified a new role for themselves as educators. This was expressed as a positive experience of supporting team colleagues, which provided a sense of confidence and achievement.

It’s like passing onto your colleagues isn’t it? They see you doing these things and you say well this is what we should do. (Care Home 4)

So we learn from each other so you know it’s interlinked thing …. she may know there’s a habit with a client, I may not know so I pass it on to her and that person can pass it on and so that it makes life easier. (Care Home 5)

In one home they had taken this further and described sharing their learning more widely with colleagues working in homes within their wider organisation.

Discussion

This study highlights the importance of understanding care home staff experiences of research participation and ways to enhance their engagement as active members of the team.

We sought to complement previous research that has triangulated the views of staff, residents and family carers (Harmer & Orrell, 2018) by exploring the multi-disciplinary experiences of a cross section of staff from direct and indirect care roles. Care delivery is the product of the way in which different staff members work together and here we aimed to understand the research experience from the team perspective. Building on our exploration of staff views prior to participating in the WHELD study (Lawrence et al., 2016), this project expanded our understanding of the experiences and actual impact of being involved in the study, which contributed to the design of the subsequent larger follow-up study (Ballard et al., 2018), for example, by informing the content of research staff induction training. For the care home staff and the research team the project raised awareness of unexpected outcomes, such as unanticipated changes to structures and organisation of work, and gave care staff the opportunity to discuss the benefits and challenges of participating. The project will be relevant to other research teams designing and delivering research in care homes.

Learning from this study adds to the broader literature on the importance of adequately preparing researchers in their approach to and engagement with care home staff. Our findings support many of the recommendations in the ENRICH toolkit and previous studies that suggest that a collaborative approach that seeks the views of care staff from the outset, provides positive feedback, and is non-judgemental of care home practices offers an effective method of engagement (Lawrence and Banerjee, 2010). Clear jargon free communication is also essential. Consideration should be given to the terminology used when discussing research with care teams. The finding that the word “random” had a different meaning in research from its lay usage echoes previous suggestions that the term “intervention” can have negative connotations for care staff (Lawrence et al., 2016). Ensuring that there is adequate time and repeated opportunities for staff to receive information and seek clarification on their involvement is an essential part of this process.

Care homes are complex organisations which juggle different roles as homes, businesses, workplaces and (sometimes) research sites (Luff et al., 2011) so it is imperative that researchers are sensitive to the cultural context. Lawton et al. (2015) found that it was the emotional demands of trial work, rather than simply the logistical and practical components, that made the involvement so challenging for staff. This included the emotional stress of research targets, balancing research roles with clinical responsibilities and having to manage the hopes and expectations of patients. Recognising that care staff’s priority to meet residents’ needs is both physically and emotionally demanding work must form the basis of any involvement. The role of positive affirmation of staff skills was a key activity for researchers in supporting staff involvement and willingness to try new activities.

Staff highlighted a number of ways in which collaborative working with researchers, amongst themselves and their local community can contribute to the overall delivery of research studies and shape the design, development and dissemination of findings. The importance of teamwork in improving quality of care is well documented (Perry, Galloway, Bottorff & Nixon, 2005) and our findings suggest that interventions which encourage team work can enhance the experience of care home research. Inviting relatives to become more involved in care home life as part of the study was experienced as a highly valued means of relationship building and as a source of support for staff, but was not easily achievable across all the settings. Previous studies have shown that engaging relatives in training sessions and promoting an inclusive ethos within the home can enhance communication skills and empathy (Palo-Bengtsson & Ekman, 2002). Our findings suggest that it may be helpful to create further guidance for both researchers and staff about how to develop successful collaborations with family members to guide positive practice in the future. Examples of this include holding regular meetings and events with all level of staff in a home, family members, and members of the wider community and health teams to enable participation and feedback.

One particularly positive element staff highlighted was the sustained period over which they worked with the research team to develop trust and confidence during the project. Whilst not all research designs can accommodate this, it is important to consider how consistent and sustained collaboration can be incorporated to best effect. Our study also revealed consensus among staff that participation in research could benefit their own work and enhance their status among relatives and care commissions as well as challenge pervasive public negative stereotypes of their profession. This places a responsibility on research teams to promote the visibility of staff achievements within the care home and the wider community.

One of the strengths of this qualitative study was that it was inclusive of a cross section of care home staff with different experiences of research participation. However, there are also limitations to consider when interpreting the findings. All the participating homes in the RCT had been selected from the CQC register as adequate or good and therefore may have had processes and practices that are more robust than homes rated as requiring improvement, possibly facilitating their engagement with research. The study sought to reduce selection bias and engage staff with a range of views and experiences, but it is possible that those with more positive views and interest in research consented to participate.

Conclusion

Participants spoke at length about their experience of the research and identified constructive ways that working with researchers could benefit all parties: themselves, researchers, residents and their families. The data are clear that a collaborative approach that acknowledges the expertise of staff and listens to their concerns, particularly around time pressures and capacity to undertake activities is essential. The need for clarity of expectations at the start must not limit the opportunity for care homes to acquire sustained benefit in the organisation and delivery of care through tangential learning arising from research participation. Identifying anticipated barriers and strategies to facilitate intervention uptake and delivery can help reduce the “implementation error” found in care home research whereby a failure to report positive outcomes may be a consequence of low treatment fidelity and the practical difficulties in conducting applied research in routine care settings. It can also guide future evaluations by highlighting influential barriers and facilitators that should be measured within process evaluations examining the quality of implementation (Vernooij-Dassen & Moniz Cooke, 2014).

Acknowledgement

We would like to thank all the care home staff that participated in this research. We are grateful to them for sharing their time and and for helping us to understand the research experience from the staff perspective.

Disclosure statement

The authors report no financial interest or benefit arising from the direct applications of their research.

Additional information

Funding

This project was funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0608-10133). The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the funder or Department of Health.