Participants
In total, 21 interviews were conducted (see Supplementary Table S3; Care Home Participants, for details). Fifteen care home staff participated from six care homes. Two care homes were inconsistent in their use of NEWS, while the remaining four were engaged. Two care homes that were not engaging with NEWS did respond, but declined to participate. A variety of staff were interviewed: eight carers/senior carers, one registered nurse, and six managers/deputy managers. Fourteen interviews were conducted face-to-face in care homes and one was held over the phone. Interviews were one-to-one bar two that were dyadic (two participants interacting in response to open-ended questions).
Six interviews were conducted with health professionals: one GP who managed a practice, three older person specialist nurses, one nurse from a 24-hour care service, and a CCG employee involved in intervention support (see Supplementary Box S2; Additional information on recruitment and data collection). Specialist nurses visit care homes regularly, providing brief education to staff and health care to residents, acting as a link between the care homes and external services, aiming to prevent avoidable hospital admissions. The 24-hour care service provided short- term, responsive, multidisciplinary health and social care in the community, including to care homes. Because of their interaction with multiple care homes, these interviewees had a broad overview of how care homes interacted with NEWS.
Key themes
Three key themes were identified: acknowledging and exploiting the benefits of NEWS; inhibitors to engagement and integration; and shortfalls in communication.
Acknowledging and exploiting the benefits of NEWS
Care home staff recognised the potential advantages of NEWS, with some expressing a sense of empowerment. Having a NEWS measurement to hand often, though not always, enabled staff to communicate more effectively with external healthcare services, with a view to avoiding unnecessary hospital admissions. Using the tablet computer to input and calculate NEWS was viewed as straightforward:
‘It does give you the backup when you’re ringing for professional help … they, kind of, listen a bit more.’
(Dyadic interview, deputy manager [DM]1, care home 4)
‘It doesn’t have to be a nurse or a senior nursing staff, it can be a carer who can do it … it makes me feel important when I’ve got that little case there [containing NEWS equipment] .’
(Carer, care home 1)
Inhibitors to engagement and integration
Data provided by the CCG indicated that only one-third of care homes were regularly measuring NEWS. Measuring vital signs, particularly respiratory rate, posed a challenge for some care home staff, resulting in inaccurate or absent readings being used to generate a NEWS. There was a perception among health professionals that care home staff sometimes took observations at inappropriate times or failed to account for variables that could result in an inaccurate reading (for example, a resident’s nail varnish interfering with pulse oximetry).
Health professionals believed that some care homes were struggling with basic elements of care, such as hydration, making the introduction of NEWS potentially inappropriate:
‘Sometimes get the oxygen saturations and heart rate around the wrong way … And that is reading off the actual pulse oximeter … Or they won’t actually take the full score, or the score will be inaccurate because they haven’t done a respiratory rate.’
(Nurse, 24-hour care service)
‘I cover nine homes and I could probably straightaway think [specific care homes] are doing well with it … But, that’s the minority. The rest are either struggling or paying lip service … sometimes I think “would I even want them to be worrying about the NEWS scores, would I actually want them to be worrying about more basic: have they given them a drink; have they made sure that they’ve been up to the toilet?”.’
(Specialist nurse 2)
With their broad view across multiple homes, health professionals were aware of regular changes in management and high staff turnover, leading to inconsistency in training and skill level across care homes. Differing levels of knowledge and skill also existed within care homes, with night staff and agency workers often having less extensive training or lower expectations of responsibility than day staff. This lack of continuity meant that not all staff were aware of or trained in NEWS, creating extra work and frustration for health professionals. This was problematic as the 24-hour care service required the sharing of a NEWS when care homes needed assistance:
‘One of my homes has had a different manager every year. The turnaround can be very rapid … it causes a lot of unrest amongst everybody … some of the homes haven’t got stability.’
(Specialist nurse 3)
‘Information is not consistent. Changes in staff does not help.’
(GP)
‘But I think when you have got agency staff, who — sometimes they don’t even know that the equipment exists — I think that’s where sometimes you get some of the problems. Especially if they cover, kind of, nightshifts and weekends.’
(Specialist nurse 1)
Care home staff viewed their work as valuable, demanding, and often unpredictable, which health professionals also recognised. This unpredictability was positioned as a potential barrier to using NEWS. The residents were at the centre of this complexity, with high level of dependency and cognitive impairment, which could result in residents becoming agitated by NEWS equipment. Thus, staff sometimes faced a choice between not obtaining a NEWS and causing distress:
‘Staff who are in the homes on minimum wage and we are expecting them to do more within their role and within a short space of time, when possibly the residents could all be high with anxiety one day and there could be chaos in that period of time that won’t allow them to engage more with other residents.’
(Nurse, 24-hour care service)
Researcher:‘So, what were your initial thoughts about [NEWS] ?’
Specialist nurse 2:‘I thought it was a very good idea at the time and I suppose that my thoughts have possibly changed over a period of time. I now can understand the intricacies and the difficulties that [care home staff] … come across.’
DM2:‘With it being predominantly dementia, there are a few that won’t tolerate it or get frightened by the blood pressure usually, isn’t it, the machine?’
DM1:‘Yes.’
DM2:‘So that will be documented and risk assessed and there’ll be something in place to say that, you know, we’re not going to cause them distress with that if they’re not tolerating it.’(Dyadic interview, care home 4)
Care home work was viewed as undervalued, because of its demanding nature and low pay. Asking care home staff to do more complex work like the NEWS was, at times, framed as problematic, and likely to compromise the time carers had with individual residents. Finally, the technology could also cause a barrier to using the NEWS equipment, with care homes typically citing failures with Wi-Fi connections and tablet computers not charging.
Shortfalls in communication
A key purpose of NEWS was to improve communication between care homes and the NHS. The data suggest that this was not fully achieved, partially as a result of suboptimal training. Training delivered to care home staff covered the theory behind NEWS and practical experience of taking vital signs with colleagues. Yet the training was perceived as being aimed at the wrong level: too high in the eyes of one of the health professionals and insufficient in the eyes of some care staff, failing to prepare staff adequately for the challenges of taking vital signs from residents:
Researcher:‘What kind of training did you receive around [NEWS] … ?’
Carer:‘Very low … if they [fellow care home staff] had additional training or more quality of training, they may feel more amenable to actually engaging with it.’ (Carer, care home 3)
Consequently, health professionals reported inconsistencies in how and when NEWS equipment was being used, with some homes only using it to take observations without calculating a NEWS, and others only using the equipment now and again, thus failing to maintain monthly readings. As a result, the key purpose of the intervention appeared to have been lost.
In addition to problems with the training, the support being provided to care homes was limited, with one non-clinical CCG employee providing technical support across all 47 care homes. The clinical support care homes received was described as impromptu, such as when a health professional was on site or available on the phone. This resulted in unscheduled additional work for these health professionals. Care home staff were typically not given a strong foundation for engaging with the NEWS, and often lacked adequate longer-term support:
‘… respiratory rate, I have often talked through it on the phone; “I want you to count for a minute, I want you to count how much their chest rises and falls”. Just so we can get a value.’
(Nurse, 24-hour care service)
Knowledge of the intervention was variable. Some voiced frustrations at NHS services not always being aware of the NEWS or that it was being used in care homes. Care home staff and a specialist nurse also reported that services did not always listen to, or take account of, the knowledge and views of care home staff with regard to their residents:
‘… [care home] had a little bit of a concern, done [resident’s] readings, and their readings have been really out of sync, but … normal [for the resident] . But, looking at the [resident] themselves, they weren’t that concerned for admission. But, based on those readings, the … service haven’t gone out to check them, they have just said, “You need an ambulance.” … I don’t think they particularly did, and if [the service] had gone out to see them, then maybe that could have been avoided … I don’t think it’s so much that the readings haven’t been correct; I think it’s more that they don’t listen to the staff so much about what the patient’s ‘normal’ is.’
(Specialist nurse 2)
‘If we have to ring for paramedics or 999, the triage can be just horrific ... they’ll say “what’s the NEWS?” … And I think receptionists at GPs … you would ring and say “we’ve done a NEWS score” and they’d be like “what does that mean?”.’
(Dyadic interview, DM2, care home 4)
Representatives from care homes were not included in meetings held by the CCG about the ongoing implementation. Views of care home staff were reported secondhand, which meant that people at the frontline of the implementation were not directly involved in discussions about how it could be improved.
Findings against Normalisation Process Theory (NPT) constructs
Findings were considered against NPT constructs to identify where the implementation faced barriers and where improvements could be made (see Supplementary Table S1; Responses to the NoMAD survey instrument, for details).
The concept behind NEWS was appreciated, the potential benefits of NEWS were understood, and NEWS was perceived as a legitimate part of care home work by health professionals and care home staff alike. This suggests an intellectual level of coherence, cognitive participation, and collective action. Some care home staff described the benefits of NEWS and the confidence they gained from providing objective data to external services. Positive remarks typically came from, or concerned, care homes with a long-standing manager and staff, suggesting that homes with a stable staff base may be better suited to this complex intervention.
NEWS faced many real world barriers in its implementation in all NPT constructs. NEWS equipment was commonly not used as intended, and vital signs could be taken at inappropriate times or inaccurately, undermining coherence and cognitive participation. Both appropriateness of the training and the legitimacy of care home staff taking vital signs observations were questioned. Not all staff were trained in NEWS, causing a barrier to collective action. According to participants, NHS staff were not all aware of NEWS, some had not incorporated it into their triage protocol, and they failed to acknowledge that care home staff had a unique understanding of their residents. This hinders collective action and suggests a lack of coherence and cognitive participation among such services. Specialist nurses were not formally involved in providing support to care home staff in regard to NEWS, again impeding the integration of NEWS across the aforementioned constructs.
A considerable barrier to engagement with and integration of NEWS is based in coherence and reflexive monitoring. First, the initial implementation occurred over a large number of homes over a short period of time, providing limited time for sense-making work. In addition, key frontline stakeholders, such as care home staff and specialist nurses, were absent from implementation meetings, therefore reducing the capacity for their concerns to be voiced and discussed with those responsible for the ongoing implementation. These issues created a fragmented form of implementation that created a barrier to sense making and action, as well as reflexive learning and adaptation.
