The first phase of this study set out to explore the experiences of care staff in managing the healthcare needs of residents, in particular those living with dementia and whether they faced any challenges in managing these needs. One care home served as a case study site, from which data were collected. During a period of familiarisation the care home was visited on 17 occasions typically lasting 4-5 hours, over a period of three months, in order to deepen
understanding of the context, the care provided in this care home and any challenges facing the care staff. A number of formal interviews were conducted and documentary evidence collected. As previously discussed it is important for a practitioner researcher, especially one who is an ‘insider’, to take into account any influence they may have on the results, or how they are interpreted (Hewitt-Taylor 2002). For this reason field notes (FN) and a research diary (RD) were also kept, recording the day-to-day progress of the study. Together with the researcher’s thoughts, feelings, and reflections on what was uncovered in the case study and how this related to the researchers own preconceptions and experience of care homes. These field notes served as an additional source of data. For example the following reflection concerns district nurses insisting on a paper referral
…..An issue raised was around referrals and the problems they have when they know that a DN is due to visit and something has happened to a resident….they are being told that the nurses are not able to do anything until they have a referral from a GP. I don’t believe, from my experience, that this is right, as we are a service that is able to take referrals from anyone; people are even able to self- refer….They even gave an example of this happening, when a resident developed blisters on their legs. The problem was that it took 4 days for the whole process to happen, i.e. the GP to send the referral to the call centre, by which time she had
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Familiarisation
Becoming familiar with a ‘field’ is a feature of ethnographic research, but is also a useful tool in other forms of research, as it can enhance the quality of data collected during later stages of a study (Barley 2011). Prior to the start of this study any knowledge or experience the researcher had of the care home sector had been gained through her role as a district nurse, visiting care homes to provide nursing care for residents and she had never had the opportunity to, or spent any significant time in, such a setting. Schensul et al (1999) suggest four areas that a
researcher needs to become familiar with during such a phase. The first is mapping of the setting, which involves the researcher familiarising themselves with the location and focusing on first impressions, which can serve as a reference point for later observations. Secondly it is important that the researcher becomes acquainted with the norms, beliefs, rules, rituals and language of the location, as this will enable them to develop a greater understanding of the setting and the rules that govern it. This is especially true if a researcher is working in a setting that they know little about. Thirdly such a period gives the researcher the opportunity to begin building relationships, which are necessary if initial and on-going access to a site is to be granted. Finally it provides an opportunity to learn how best to collect and record data, i.e. the practicalities of doing field work (Barley 2011, Barley and Bath 2014). This period of
familiarisation served a number of purposes in this study. Firstly, it allowed me to familiarise myself with the organisation and to gather a better understanding of the context in which care staff were working, which is recommended when conducting research in a care home setting (Luff et al 2011); leading for example to the realisation that it would not be possible to ask staff to leave their unit to be interviewed, and that a different approach would be needed. Secondly, it offered an opportunity for establishing rapport and the building of relationships with participants so they would feel more comfortable in my presence, as well as feel that they could start to trust me. Thirdly, spending time at the care home meant that I was available to carry out interviews at times that were convenient for the staff, making the most of any opportune moments that arose.
At the commencement of data collection I was given permission by the care home manager to spend time familiarising myself with the care home. The manager introduced me to members of the staff and explained what I was doing there. A letter of introduction, together with an
information sheet explaining the purpose and aims of the study and a copy of the consent form, were sent to all members of care staff. I also met with members of the care staff during the first couple of weeks to talk with them about the study. This was felt to be important as although the manager of the care home had given her approval for the care home to participate in the study, this didn’t guarantee that other members of care staff would wish to participate. The care home comprised 6 separate units, each housing 10 residents. After a discussion with the care home manager I was given permission to spend time on each of the units, visiting each on at least two occasions. In my role as a district nurse the manager also gave me permission to engage with both the staff and residents, although the latter interactions were not used as sources of data.
The period of familiarisation took place over 3 months, with the care home visited on 17 occasions. This time was used to gain a better understanding of the day-to-day care provided
by care staff, the documentation used, and to build relationships with the care staff.
Understanding gathered during this period informed both my thinking about care homes and also the questions used during formal interviews (n=7) and the focus group (n=1) carried out at this care home. Informed consent was given by all interviewees and it is from these interviews that data in regard to the case study site were drawn. If asked, because of my experience as a nurse, I would also provide practical support to the care staff, such as supporting residents at meal times and taking part in activities on the units. During time spent on the units I spoke with a number of the residents, as well as their family members. When this happened care was taken to explain who I was and why I was at the care home and to answer any questions or concerns that they might have had. During these periods I also observed provision of care to residents in the communal areas. But as informed consent was not sought from residents such observations have not been used as data. However, as an experienced district nurse it would be disingenuous to suggest that such experiences hadn’t informed my thinking, especially in regard to the care needed by a resident living with dementia. Field notes in the form of personal reflections were recorded following each visit to the care home
The opportunity to spend a prolonged period of time in this care home proved to be invaluable, as the reality was that this was the first time I had spent any significant period of time in a care home. As I was not there in my professional capacity as a district nurse, I could not hide behind the excuse of giving physical care and instead was able to spend quality time with the care staff. It offered me the opportunity to talk with care staff away from my professional role and to hear their thoughts and experiences. It enabled me to gain a better understanding of the care they were providing, as well as the challenges the care home staff were facing, seeing it all through a new set of eyes. During this phase of the study, as a practitioner researcher, I reflected on the findings and came to realise that, as a district nurse, I was ignorant about care homes and the challenges that they and their staff were facing, reflections that subsequently influenced the direction the remainder of the study took. As evidenced by the following note reflecting on what had been learnt from the case study site
…..What did I learn from the case study? That they are caring for people with multiple needs, including physical, psychological and social needs. Residents were often admitted with significant health problems, yet residents appeared on the whole to be relatively well. This could have been a result of the many healthcare professionals that were involved in the residents care and on whom they were heavily reliant. It also appeared that these healthcare professionals had little understanding of the care staff role, or the care they were permitted to provide, nor did they have any real understanding of the constraints put on them. It was also interesting that few of the care staff had any dealings with these healthcare professionals, with this role left to the team leaders…..Based on these findings I want to explore with others what is making it harder, or preventing care staff from meeting healthcare needs…..I want to find out what it is that they value from the
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district nurses and the sort of relationship that they need. If some kind of nursing input is needed what could it look like, what do they need? …..RD 018, p250-251
Field notes
Field notes were kept during the study, and were used to gather data about the context of the care home, and to inform the researchers thinking and reflections during Phase 1. Field notes are the ‘backbone of collecting and analysing field data’ (Gray 2009) and are used to give a narrative account of what is observed in the field. These notes can be used in both analytical and interpretive ways, to record not only what is seen during a period of observation, but also to synthesise and try to understand any data collected (Polit and Tatano-Beck 2008). Field notes can be both descriptive and reflective. Descriptive field notes will include descriptions of observed events, conversations, actions, dialogue and context and should be as complete and objective as possible (Polit and Tatano-Beck 2008). Field notes such as these were recorded during each episode of data collection on a unit including such information as: description of the care home and individual units, the numbers of residents, numbers of care staff, policies and procedures and documentation used. Reflective field notes, on the other hand, are used to document a researcher’s personal experiences, reflections and progress in the field. Such field notes were recorded separately in the research diary that was also kept. The following entry records a reflection made about the dynamics between care staff, based on the group interview held with a number of the care staff from the case study site and which was later checked out during an interview with one of the team leaders
Something that did strike me from re-listening to the recording of the interview was that there appears to be a hierarchy within the care home itself. The more junior care staff appear to see themselves as just being there to provide the basic care and anything involving changes in a resident’s health, or problems that may arise, will be reported to the team leaders, who will be the ones who then speak to the healthcare professionals. They (the care staff) don’t appear to see that they have a role to play with other healthcare professionals, but appear to see themselves as there simply to do what is asked of them……RD 17, p240
It is often not possible or appropriate to record field notes at the time. However, for reasons of possible bias they should be recorded as soon as possible after the event and in as much rich detail as possible so that information is not forgotten or distorted (Brodsky 2008). As I did not feel it was appropriate to sit and write notes during my time on the units, the field notes were written up as soon as I had left the care home, usually whilst sitting in my car, when events were still fresh in my mind.
Reflection and the research diary
A research diary was used to systematically record the progress of the study, any issues or difficulties encountered, together with thoughts, feelings, ideas or interpretations regarding either the research design, or the phases of data collection or analysis (McKechnie 2008, Gray 2009). It was also used to record all reflective notes. Reflection took place at various stages of
the study, e.g. following all care home visits and interviews, during data analysis and during and after any supervisory sessions. For example, following a care home visit I would reflect on what had been seen, conversations that had taken place with care staff, personal feelings about the experience, what had been expected or unexpected, especially that which challenged my previous experiences and what were key learning points from the visit. Such reflection encouraged me to think in greater depth about what I had observed and heard. The reflective notes then enabled me to put into writing my thoughts and feelings of what had been seen, how findings possibly related to my previous knowledge and practice, and how the service might change. This process was informed by my previous experiences working as a district nurse, as well as by the literature. Supervision was an important part of the reflective process. Regular sessions were held over the course of the study, during which in-depth discussions were held with my supervisors about the study’s progress, data collection, analysis of the data and conclusions being drawn. I would be regularly challenged by my supervisors to think about the data being gathered, the strength of these data, and to reflect on my interpretations of what had been found and conclusions being drawn.
Semi-structured interviews
In order to explore in greater depth the thoughts, views and experiences of the care staff, a number of interviews were conducted during Phase 1. Semi-structured interviews were used to ensure that specific topics of interest were addressed (Polit and Tatano Beck 2007). It also meant that the sequence of the topics raised could be varied in each of the interviews, in response to the answers given by each participant, as well as allowing the interview to have a more natural flow (Dearnley 2005, Casey 2006). Although an interview guide (Appendix 12) was prepared for each interview, giving an outline of the main topics to be covered and questions to be asked, it was not followed rigidly but instead was used as an aide memoire and I would move back and forwards through the questions depending on the response of the interviewee. These interviews were also guided by my thinking and reflections developed during the period of familiarisation. For example, seeking to better understand from the interviewees the importance of ‘knowing’ a resident, the impact of nurses rushing care provision, or a lack of continuity of nurses for the person living with dementia; issues that previously I may not have considered. After each interview I would also reflect on how the interview had gone and any issues that had been raised, with each interview influencing subsequent interviews and interview schedules
A number (n=5) of semi-structured interviews were held with the care home manager. To gather information on the day-to-day running of the care home, to explore their experience of
managing the healthcare needs of the residents, as well as to feedback my thoughts and reflections on what I had seen during my time in the care home. I had, before embarking on data collection, also planned to formally interview a number of the care home staff. However, I quickly learned that when it came to conducting research in a care home setting I needed to be flexible, a finding supported by a report commissioned by the National Institute of Health Research and the School for Social Care Research (Luff et al 2011).
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As a novice to this care home I had no prior knowledge of the care home environment. The layout of the home made it impossible to take members of staff away from the work environment in order to conduct interviews in private. Each unit was staffed by two carers, one of who could be called away at any time, for example to deal with a situation in another part of the care home, or visit a GP surgery, especially if they were a team leader. The reality was that in terms of interviewing care staff I had to take any opportunity that was offered to me. For example a group interview was held with 10 members of the care staff, who were attending an all-day training session at the care home. As they were there for training purposes this meant they were supernumerary. Another day I was able to interview two of the team leaders, however one of these interviews had to be cut short when the team leader was called away. During Phase 1 a number of semi-structured interviews (Appendix 13) were also carried out with members (n=4) of the district nursing team who supported this care home. These nurses comprised one deputy team leader, two primary care nurses and one healthcare support worker. These interviews followed the same course as those of the care home participants.
Documentation
Documentation was gathered to inform understanding of the care home and the care provided. In addition some documentation, e.g. policies and procedures and CQC reports were used as data for the first of the findings chapters. Factual information was gathered about the care home and its parent organisation, which was used to give a better understanding of the care home’s context and history. Copies of the documentation, care plans and tools used by care staff when assessing and planning a residents’ care, together with job descriptions of all members of care staff, were gathered to inform the researcher’s understanding of the care staff role and the assessments and care they were providing. This understanding was further informed by their policies and procedures, which direct the care they were able to give. Finally their most recent CQC inspection reports were read, to give a better understanding of the history of the care home, as well as the quality of care they were reportedly providing.