Developing evidence-enriched practice in health and social care with older people

The project, which ran for one year in six sites across Wales and Scotland, focused on what matters to older people, carers, staff, organisations and researchers.

The project demonstrated the benefits of using research and related contextual evidence in developing services and workforces, resulting in improved wellbing for older people, carers and staff.

Key points

• The project ran for one year in six sites, five in Wales and one in Scotland.
• A key success in this approach was that it established and focused on what mattered to participants (older people, carers, staff, organisations and researchers).
• Participants chose to implement actions that promoted relationship-centred services and greater autonomy for service users, carers and staff.
• Participants used a range of evidence, including research, the voices of service users and carers, and practitioner and organisational knowledge.
• Participants used evidence to meet goals, regardless of whether they could later recall exactly what that evidence was or how they had used it.
• Evidence was used when it was presented in targeted, meaningful and accessible ways including short research summaries, stories, arts-based approaches, standard frameworks and ‘provocative statements’.
• Skilled facilitation in the use of evidence in service and workforce development was fundamentally important, responding to emerging ideas and contexts and weaving in relevant evidence over time.
• Facilitated dialogue between project participants created relationships, improved decision- making, and enabled effective learning.
• Learning and development was most successful in organisations that had a clear sense of direction, empowered their staff and involved service users and carers.

BACKGROUND

National policy in Wales and Scotland emphasises the promotion of wellbeing. The JRF programme A Better Life generated a lot of evidence about what wellbeing means for older people with high support needs and their carers, including the ‘ordinary’, often little things that mean a lot.

An alternative approach to evidence

The evidence from the A Better Life programme was encapsulated in seven challenges. To:

• develop more positive images about old age – no ‘them and us’;
• see the person behind the label or diagnosis;
• ensure that all support is founded in and reflects meaningful and rewarding relationships;
• focus on the strengths of older people and create opportunities for them to give as well as receive;
• treat older people as equal citizens, with rights and responsibilities;
• listen and respond to what older people say;
• develop innovative ways of supporting older people, and improve existing services which can include addressing ordinary things that mean a lot.

This project gauged what they meant to the older people, carers and staff who took part in the project, and helped local groups draw up their own actions.

‘Often it is the simple things that bring the most pleasure (and the lack of them can bring a sense of sadness and loss) and services do not always seem to be very good at delivering “the ordinary”’. (Blood, I. 2013. A Better Life: Valuing our later years. York: Joseph Rowntree Foundation, p13)

The All Wales Academic Social Care Research Collaboration (ASCC) and the Institute for Research and Innovation in Social Services (IRISS) formed a partnership with JRF to explore and develop an approach to using evidence to develop services and the workforce that is practical but takes into account the complexities involved; an approach that is simple, but not simplistic.

The project used a collaborative action research design involving older people, carers, researchers, managers and frontline staff from social care and health organisations, both statutory and voluntary.

Each site chose particular topics for service and workforce developments, including relationship-centred practice, positive and rights-based approaches to risk management, the development of meaningful activities, short breaks, addressing loneliness and better recording and paperwork.

Key issues in using evidence in service and workforce development

The project identified five important issues in assessing and using evidence.

Valuing and including a range of evidence
The project identified the importance of bringing together and sharing a range of evidence, including research, practitioner knowledge, the voice of service users and carers, and organisational knowledge.

Securing senior management buy-in and valuing and empowering project participants
Creating the right conditions for participants to feel valued and confident to learn and experiment was crucial. This required an approach that promoted:

• appreciation and respect – valuing participants and focusing on their strengths and the things that mattered to them;
• honesty – supporting participants to ‘say it as it is’;
• permission – ensuring senior management buy-in and encouraging participants to make humane and creative decisions according to specific circumstances rather than always following black and white rules and procedures;
• mutual trust – developed through respectful conversations;
• celebration – recognising and building on success, including the achievement of ‘ordinary’ things.

Capturing and presenting relevant evidence in accessible and engaging formats
Participants found research reports and policy documents helpful when they were summarised in plain language. They used key points from research and warmed to evidence when it was presented in the form of stories, poetry, pictures and music. Participants found examples of good practice (for example in A Better Life research) useful. They also found short model frameworks useful in helping them to conceptualise key issues, and used the seven challenges in this way. ‘Provocative statements’ were also helpful in stimulating learning and development.

Facilitating the exploration and use of evidence
Facilitation was the most important issue. A range of techniques was used to support effective discussion. This had three benefits.

• The formation of trusting relationships between participants and also with people outside the project created the right environment for learning and development.
• Collaborative approaches to decision-making were more balanced, particularly when there were associated relationship or physical safety risks.
• Thinking together helped participants to make sense of the evidence, especially when some of it was conflicting. Story sharing was a central feature of this.

Skilled facilitation enabled a responsive, rather than top-down, approach to project development. It required a good understanding of the topics being explored, the emerging context and the group dynamics. The facilitators’ task was therefore both intellectually and emotionally demanding. 

Recognising and addressing national and local organisational circumstances and obstacles
The project ran during unprecedented budget cuts and major structural change. While national policy aims in Wales and Scotland corresponded with meeting the seven challenges, participants raised concerns that the emphasis on savings was undermining this. They felt that interpretations of wellbeing appeared to focus more on independent physical functioning than a holistic view of better life including meaningful relationships. The evidence from A Better Life empowered them to challenge and counteract this in their project work, for example in the development of relationship-centred practice.

Participants also raised concerns about the imposition of simplistic and inflexible rules and guidance. They developed approaches to decision-making that meant they could respond more effectively to the wishes of older people and carers, particularly in lifestyle choices involving relationships and physical safety risks. Responding to what they perceived as the burden of poorly designed paperwork, participants in two sites developed more person-centred and outcome-focused recording. In one site they used JRF research to challenge local regulators to see beyond the formal paperwork and recognise more experiential quality of life.

Progress in learning and development was most effective where senior managers trusted and allowed participants to be creative. This required a focus on the longer term and the experiences and circumstances of the individuals being supported and the staff who supported them rather than a short-term one-size-fits-all ticking of the boxes management style (Patterson et al 2011).

Outcomes for project participants

Participants across all the sites reported enhanced wellbeing as a result of their involvement, indicating development of an ‘enriched environment’ of learning (Nolan et al 2006). Participants felt a sense of security, continuity, belonging, purpose, achievement, and significance – that they mattered, and that things could change for the better.

The evaluation revealed improved relationships among professionals and between professionals, older people and carers. There were also tangible outcomes, for example changes in organisational policy based on clear but flexible notions of professional boundaries.

Individual telephone interviews at the end of phase one identified the importance of stories helping participants think about evidence. After phase two, participants indicated they had drawn on many sources of evidence, but they could not unpick the sole impact of research; it was melded with other evidence into tacit guidelines (‘mindlines’).

Project costs and sustainability

The project’s main costs were external facilitation, staff time and venue hire. What participants valued most was the time to think together, and encouragement from the facilitators. Costs could be reduced by using internal facilitation led by research-aware practitioners.

Participants claimed that compared with their previous experiences of training or consultancy, the project’s investment in supporting staff to develop their practice together was time well spent, leading to more significant improvements in care and morale.

Participants were keen to continue beyond the life of the project. Many of the resources and techniques developed will be made available to a wider audience through an interactive online resource.

Conclusion

The project demonstrated the benefits of using research and related contextual evidence in developing services and workforces, resulting in improved outcomes for older people, carers and staff. The fact that the ethos of A Better Life was in tune with the views of participants greatly contributed to the success of the project, along with the use of a carefully designed, but flexible approach – simple but not simplistic.

About the project

This was a one-year collaborative action research project to develop a sustainable approach to using evidence in health and social care. It was done by a team of six people led by Nick Andrews of Swansea University.

Download the full report here: http://www.jrf.org.uk/sites/files/jrf/evidence-older-people-full.pdf