Introducing CHARM: the Care Home Action Researcher-in-residence Model

Author details

Isabelle Latham is senior lecturer and Faith Frost is research associate, both at the Association for Dementia Studies (ADS), April Dobson is head of dementia care and well-being at Hallmark Care HomesSuzanne Mumford is head of nursing, care and dementia at Care UK, and Tracey Williamson is an honorary professor at the University of Worcester and consultant nurse for dementia at Betsi Cadwladr University Health Board.

Carrying out research in care homes can be challenging because it fails to consider resources within those homes or take a collaborative approach.  In the first of a series of articles Isabelle Latham and colleagues introduce their answer to this problem, the Care Home Action Researcher-in residence Model (CHARM), and explain how it works. 

Conducting research in care homes is widely acknowledged to be worthwhile but challenging (Luff et al 2011). It is not uncommon for care home research to experience substantial difficulties in engagement, data collection and adherence to interventions, all of which ultimately affect outcomes and research effectiveness (Vernooj-Dassen & Moniz-Cook, 2014, Testad et al 2014). Our work, funded by Alzheimer’s Society and Dunhill Medical Trust, aimed to investigate and suggest solutions to the challenges of care home engagement in research. 

For the Association for Dementia Studies at the University of Worcester we understand research challenges in care homes to occur for two main reasons: firstly, poor consideration within research design and researcher engagement of the resources and capacity within care homes to support research processes. And, secondly, lack of meaningful collaboration, leaving staff feeling researched “on” rather than “with”. 

To tackle these concerns and to effect lasting change, what is needed is an approach that fully appreciates and is responsive to the history, needs and uniqueness of each individual care home. It should also enable research to be developed from within care homes themselves while educating, empowering, and skilling up members of those communities (Fossey et al 2018, Luff et al 2011). 

To address these challenges, we engaged with senior leaders from four care home providers (Care UK, Hallmark Care Homes, Sanctuary Care and Assured Healthcare Solutions) to develop a workable model for research engagement that could be explored through a research collaboration. Beginning in this consultative manner was important to ensure that the complex culture and climate in care homes was considered in model development (Killett et al 2014. Brooker & Latham 2016), rather than researcher perceptions dominating.  

These senior leaders reported that marketing, regulation and a genuine desire to enhance resident care and staff experience all helped to promote participation in research. But they also related varied experiences of participating in research and an awareness of the complications it can cause for care homes. In imagining a suitable model, these leaders expressed a marked preference for an approach that included the following:  

  • a strong presence by the researcher providing practical support to the care home 
  • opportunities for different levels of engagement within the care home  
  • inclusion of residents, families, and staff at all roles and levels 
  • focus on “real-world” problems, enhancing care practice and care experiences 
  • developing ongoing relationships with the care home post-project 

Our Care Home Action Researcher-in residence Model (CHARM) was designed to encompass these principles.   

What is CHARM? 

The researcher-in-residence model aims to develop and support an action-research culture in participating care homes. It achieves this by using two researchers with experience of working in care homes to regularly call in on staff, residents and visitors, build relationships and work alongside them to design, conduct and report on research that is of importance to the care home itself. Their broad role is to:  

  • build an appetite for evidenced-based practice through consultation, awareness-raising and targeted training  
  • identify relevant topics or issues for small research projects within the home, generated through consultation with staff, family and residents  
  • support key personnel to design, carry out and report on their internal research projects.  

Through this model, research awareness and competence is fostered in an accessible, supportive and friendly way, producing impact and outputs that are directly relevant to the lives of residents, staff and visitors.  

Researchers-in-residence visit each care home for approximately 1.5 days per week between them, supplementing this with email and telephone calls. They closely support the research and model the action-research approach. In particular, the two roles allow one (a research associate) to focus on involvement of families/visitors while the other (a senior research fellow) concentrates on staff and organisational engagement. Both researchers maximise opportunities for resident engagement by encouraging flexible opportunities for involvement to match different abilities and preferences.  

To provide structure for the researcher-in-residence work, a research working group is established by the care home. This consists of a senior leader from the parent organisation, the care home manager and two “co-researchers” drawn from staff, visitors or residents. Together, the researcher-in-residence and research working group follow successive action-research cycles (see figure 1). In addition, quarterly whole team training days – bringing together multiple care homes – provide training on key aspects of the action-research process led by the senior researcher and encourage peer-to-peer engagement.  

Action research approach  

 Action research can shape practice development in keeping with a systematic, cyclical process of activity, evaluation, reflection and implementation of change (Koshy et al 2010). It is a context-specific approach to designing and conducting research that is focussed on improvement (McNiff et al 2003, Meyer 2006, Schmuck 2006).  

Crucially, researchers-in-residence who implement action research operate from within a setting rather than being unfamiliar figures who come in from outside as would happen in conventional research. These features serve the intentions of CHARM well. In particular, the participatory nature of action research lends itself to relationship-building and empowers participants to become co-researchers; learning by doing research that matters to them (Luff et al 2011, Meyer 2006) in a safe, supportive and encouraging environment.  

Figure 1 shows the most useful features of pre-existing action research cycles as identified by our participating care homes at an early training workshop. It is specific to CHARM and was created to be used in each home’s mini-studies. 

Figure 1: Action research cycle

Evaluating CHARM  

CHARM was implemented by four West Midlands care homes owned by different organisations as part of the pilot project. These organisations were chosen to represent a range of different provider-types and were co-applicants to the project, having contributed to consultations about the design of the model. Given the exploratory nature of this project, care homes were selected by their owning organisations based on geographical proximity and ability to participate.  

This pilot project was double-layered because the aim was both to evaluate the CHARM approach and support participating care homes to undertake their own mini-studies. Figure 2 illustrates these two layers and the expected outcomes for each layer.  

Figure 2: Two layers and expected outcomes

The initial project was scheduled for 12 months (October 2019-September 2020) with the intention of achieving two action-research cycles, corresponding to two mini-studies, per care home. But due to the pandemic, the study was paused between May and October 2020 and then extended until September 2021 to allow reduced intensity for the participating care homes. Initial research time and resources were elongated across the extended project, the primary differences being as follows:  

  • virtual-only support from researchers-in-residence (March 2020-June 2021) 
  • only three out of five face-to-face training days delivered with remainder replaced by virtual group and individual sessions.  
  • adaptations to planned mini-studies due to changes in staffing, resident and family availability and lack of physical presence of the researcher-in-residence.  

 

Aim  Research Question 
  1. To develop active research involvement and collaboration in care home settings through implementation of the CHARM model 
What are the outcomes of involvement in CHARM for care home staff, family and residents? 
  1. To deliver an effective model that meets the needs of partners 
What are the barriers and facilitators of implementation of CHARM? 
  1. To evaluate the model and establish potential for improvement and up-scaling 
What are the processes/structures of impactful involvement in CHARM for staff, family and residents?  

What conditions are required for effective scale up of CHARM? 

Table 1: Overall project aims and research questions 

Qualitative and quantitative means were employed to answer our research questions on aspects of CHARM (see table 1): measures of staff stress, satisfaction and burnout; measurement of care home standards; reflective diaries and in-depth interviews with all participating care home managers, staff and provider organisation representatives.  The overall project was approved by the University of Worcester ethics committee, as were the individual mini-studies. 

Preliminary findings   

Final analysis of the CHARM data was under way as this article goes to press and the full findings will be discussed in a future article in this series. However, here we can share the preliminary findings relating to the mini-studies carried out by the care homes themselves. These are three-fold.  

Firstly, CHARM participation was valued enough by the care homes to continue despite the pandemic and produced positive impacts for care homes and staff. Each care home was given several opportunities to withdraw from the project in recognition of the pressures posed by the pandemic, but all opted to stay involved.  

Care home staff taking part reported increased interest, awareness and confidence in conducting research as a result of participation. Overall, each care home was able to complete two mini-studies as intended, amounting to eight projects overall which are summarised below. The first project for each home was initiated prior to the pandemic, so had to be paused and re-designed. The second project was planned later and already took account of the changed circumstances.   

Our second preliminary finding is that a primary facilitator of success was flexibility and adaptability enabled by the combination of action-research method and the researchers-in-residence skills. Together these led to continued engagement and implementation of mini-studies in the homes, despite challenges such as: changes in key personnel, reduced staffing, over-extended staff, changes in care home motivation and focus, and sudden changes in resident need.  

In fact, the model created an ability to pause involvement, change the pace of the research, alter levels of support and refocus the research itself to adjust to the ever-changing environment in the homes. While the pandemic magnified these challenges, all of them are familiar to care home research in normal times.   

Thirdly, resident and family/visitor engagement was not as significant as intended at the outset. The implications of the pandemic resulted in mini-studies that focussed less on resident and family experiences than initially hoped by both the CHARM team and the care home research working groups. Social distancing, restricted visiting and increased pressures on staffing meant that data collection focussing on residents or families was not always feasible or appropriate, especially without in-person support by researchers-in-residence.  

Most significantly, however, encouraging research working groups to engage with residents and families in initial consultations to decide exactly what to study was complicated prior to the pandemic in all care homes.  It suggests that this was not a problem caused by the pandemic as such but something more endemic to the homes. 

The eight mini-studies 

Care Home 1 
Project title and focus  Key findings and outcome 
What is the best way to support staff to use the PAL tool to improve dementia care? 

 

A study to compare applications of the Pool Activity Level tool (Pool 2017) was halted because of changes in the resident community and urgent introduction of PAL tools due to the pandemic. It was revised to describe the process of using the PAL tool during the pandemic and to allow future exploration of the initial question. 

Findings: Initial project halted, but a number of tools had been developed which are now successfully used within the organisation (eg. a board game)  

 

Outcome: Action plan to enable the care home to complete the original comparison study when resident and staff community return to pre-pandemic levels. 

(*) Moving forward from an outbreak: What has been the experience and impact of the pandemic from staff’s perspective and how have we moved forward?  

 

A survey and interview study to discover staff’s pandemic/outbreak experience and identify successes/challenges of support  

Findings: Stress and grief were common and staff experienced conflict between work responsibilities and a need to protect their own families. However, staff were motivated by a high level of commitment to residents. Support from management and team unity were key factors in helping staff cope.    

 

Outcome: An action plan to share the staff story with the wider care home and explore options for how residents and families can also tell their story. Results fed into organisation-wide guidance on how to support staff through periods of extreme stress. 

 

 

Care Home 2 
Project title and focus  Key findings and outcome 
How has communication in the home been affected during the time of covid for family members and residents and what can we learn from our approach? 

 

An exploratory study to examine and improve methods of communication in the home was adapted to focus on communication with families and residents during COVID as this was identified as an urgent need 

Findings: Communication improved during the pandemic and efforts have been highly valued by family members and residents.  

 

Outcome: Action plan to retain features of effective virtual communication alongside return to pre-pandemic visiting/ communication   

A project to find out resident, visitor and staff preferences and suggestions for our new garden space and associated activities 

 

A survey, focus group and resident consultation to shape the new garden space due to be built in the home. 

Findings: The current garden is used infrequently and designed poorly. Residents, staff and families have overlapping specific suggestions and preferences for improvements  

 

Outcome: A blueprint for the home’s new garden space based on preferences. An action plan for reviewing impact on usage once new garden is in place.  

 

Care Home 3  
Project title and focus  Key findings and outcome 
What is the best way to gather life history about our residents?  

 

A study to compare different methods of information-gathering for collecting residents’ life history was adapted to focus on families’ understanding of this area as staff capacity was reduced but family engagement via virtual means was high.  

Findings: family members are unfamiliar with “life history” work but do understand its importance to good care. They have a preference for contributing to written documents and are keen to be involved.  

 

Outcome: Action plan to design a new life history process for the home and to engage with family members as key drivers of the change.  

How well has our care home used technology to adapt to the changes created by the pandemic? 

 

A survey of staff and families to reflect on the multiple technologies introduced because of the pandemic and identify areas of improved practice to be retained. 

Findings: Technology used to facilitate connection between families and the home/residents have been successful. Staff communication in the home was poor.  

 

Outcome: Action plan to maintain key uses of technology post pandemic. Improvements in staff communication required. 

 

Care Home 4 
Project title and focus  Key findings and outcome 
Home in time for tea; an exploration of mealtime experiences  

 

An exploratory study to investigate the impact on residents of changing the main mealtime and introducing food-preparation activities. This had to be halted due to social distancing’s impact on mealtime routine. Rationale for this proposed change was then overtaken by the impact of the second project. 

Findings: The initial project had to be halted, although preliminary findings showed that changing mealtimes (without implementing food preparation activities) neither positively nor negatively affected the residents.  

 

Outcome: the second project’s impact meant that this project was no longer necessary in its initial form. A report of the initial findings and possible action plan to repeat the study in the future was created. 

(*) What do you need to carry out your role and improve quality of life for residents on our dementia community? 

 

A two-stage survey and focus group study to consult and involve the staff in management initiatives to improve the care culture  

Findings: Staff identified a need for improved communication, support and valuing and gave suggestions. Following implementation of an action plan built from staff suggestions, staff showed improved outcomes in these areas, although further work was still needed.  

 

Outcome: Ongoing action plan to continue with management actions and review staff feedback again. 

(*) We hope to share the full findings of these studies in separate articles as part of this series 

 

Conclusions  

Overall, the CHARM project has been successful with preliminary findings showing it is a much-appreciated, workable and impactful model for the care homes that took part. Success was achieved despite the pandemic, which threw light on the barriers faced during research and processes for counteracting them.   

The project has provided a firm grounding for a future model that can function in the most testing of circumstances. Adaptability and flexibility were required in completing the eight mini-studies and are inherent in the action-research method.  These qualities were a primary facilitator of CHARM, even though they do not necessarily fit well with more conventional approaches to research design and delivery.   

Challenges faced in engaging families and residents appear to suggest that, as currently applied, CHARM does not sufficiently tackle barriers to their genuine involvement in research processes. “Service user involvement” is a known area of challenge in care homes generally, and so a future model will need to look further at initiatives to improve this aspect.  

We look forward to sharing further details of CHARM’s facilitators and barriers, and recommendations coming out of the project, as well as showcasing in-depth the amazing work of the care home mini-studies.  

Acknowledgements   

The CHARM project is a collaborative partnership between the Association for Dementia Studies at the University of Worcester, Care UK, Hallmark Care Homes, Sanctuary Care, and Assured Healthcare Solutions Ltd, funded by the Alzheimer’s Society and Dunhill Medical Trust (grant number 506/AS-CC-18-006). Thanks are due to the staff, residents and visitors of the four care homes that took part.  

The full CHARM project team

References  

Brooker D, Latham I (2016) Person-Centred Dementia Care: making services better with the VIPS framework. London: Jessica Kingsley Publishers. 

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