Objectives Wandering is a common behaviour among people with dementia living in care homes, driven by various factors such as enjoyment, a sense of purpose, lifelong habits, and social interaction. These elements can bring both physical and mental benefits, highlighting the need for strategies that enable safe wandering while respecting individual autonomy. This realist synthesis aimed to explore these strategies and the conditions under which they lead to successful outcomes. Methods This realist synthesis involved scoping the literature to develop initial theoretical explanations for how different strategies could support safe wandering. From this literature, we developed context-mechanism-outcome configurations, which we combined into initial programme theories. Systematic searches were then used to test and refine these programme theories. Studies were prioritised for inclusion based on criteria of relevance and richness. We extracted data pertinent to the initial programme theories and documented relevance, richness, and rigour. We synthesised data into five refined programme theories. At each stage of the process, we collaborated with stakeholders to develop and validate the strategies. Results The review included 79 evidence sources, leading to five refined programme theories. 1) Personalised Care: Emphasising the importance of staff practicing person-centred care by understanding residents, their reasons for wandering, and their life histories. 2) Monitoring: Effective monitoring requires good visual access or technological solutions that enable staff to observe residents, and detect when residents need support to walk while also enabling resident freedom and independence. 3) Navigation: Navigation is facilitated by dementia-friendly design features and environmental cues, which help minimise the challenges residents face due to diminished orientation and wayfinding abilities. 4) Managing access: Involving balancing residents' safety and autonomy. Strategies may include restricting access to unsafe areas by locking doors or using technology and camouflage, while ensuring access to safe spaces. 5) Hydration and nutrition: Hydration and nutrition (e.g., suitable snacks) is provided to prevent weight loss for residents who wander and may not stay seated during meals. These theories provide insight into supporting safe wandering, leading to improved wellbeing for both residents and staff, enhanced safety and autonomy for residents, and reduced staff anxiety. Discussion Strategies that create a supportive environment, provide physical assistance, and support hydration and nutrition enabled residents to wander safely. Identified strategies improved wellbeing for both residents and staff. However, the same strategies also led to ethical concerns around digital monitoring, deception, and access restrictions. Study registration The protocol was registered with PROSPERO (CRD42024559085).

Up to 60% of people living with dementia 'wander' in care homes. Previously perceived negatively, wandering is increasingly recognised as a meaningful activity, driven by enjoyment, routine, and social connection. Care home environments can support or hinder wandering and orientation, influencing autonomy and wellbeing. This study aimed to describe environmental features that can influence orientation and wandering within care homes. This study developed and employed an evidence-based environmental mapping tool within care homes, recruited to ensure representativeness across ownership, funding, and location. The bespoke tool integrated design criteria from existing literature, such as scale and domesticity and expert experience, addressing orientation and wandering. Visual floor plans were created, and findings were presented in alignment with environmental strategies from a realist review. The 80-item 'Wayfinding Environmental Mapping Tool for Care Homes' was developed and used in seven care homes in England (Midlands and the North). Size, layout, and design varied across care homes. Some closely resembled domestic settings, while others had a clinical appearance. Modifiable and non-modifiable features shaped care home environments. In some homes, residents could independently access kitchens, laundry rooms and gardens; whilst others restricted access. Clear signage, natural lighting, and visible routes were observed and have the potential to support wandering and orientation. This study applied the novel 'Wayfind Tool', revealing significant heterogeneity in care home environments. We found that modifiable features like personalisation and accessible seating offer cost-effective ways to create supportive, "home-like" settings, aiding orientation and wandering. Given the observed heterogeneity and the crucial environment-behaviour interaction in dementia, future care home research should increasingly integrate environmental mapping methods. Our freely available 'Wayfind Tool' serves descriptive purposes and has potential as an audit instrument to identify areas for improvement, highlighting the environment's role in supporting wandering and orientation.

Background Poor oral health among older people living in long-term residential care is associated with serious health consequences and reduced quality of life. Oral health commonly deteriorates in these settings and is often attributed to care staff workload pressures and limited oral health knowledge and skills. However, practice colleagues in our established UK care home and science partnership told us that a range of factors support and hinder them with oral care provision. Objective To identify and synthesise the individual (micro), organisational (meso) and wider social and political (macro) factors that influence oral care provision for older people living in long-term residential care. Design and method A scoping review was undertaken. Search strategies were developed by information specialists and study selection involved independent screening by two reviewers using predefined eligibility criteria. Data synthesis was informed by the Capability, Opportunity, Motivation and Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Data sources Systematic searches were conducted in February 2022 and updated in March 2026. Searches included CINAHL, Web of Science Core Collection, Embase, MEDLINE, APA PsycInfo, Google Scholar and relevant grey literature sources. Findings Sixty-three studies (reported in 86 publications) were included. The most frequently reported influences on staff behaviours were in the COM-B ‘opportunity’ domain: environmental context and resources, and social influences. Staff knowledge and skills were important determinants of capability, while beliefs about consequences influenced motivation. Key enablers included training, oral health champions, supportive leadership, assessment and monitoring systems, and collaborative relationships between care staff, residents, relatives and dental professionals. Key barriers included staffing shortages, workload pressures, limited time, inadequate training, low organisational prioritisation of oral care, and restricted access to external dental services. Interpersonal relationships were central to effective oral care provision. Conclusions Oral care provision is influenced by a complex interplay of factors at the individual, organisational and policy levels and cannot be attributed solely to care staff. While workforce pressures and limited training are important, staff knowledge, skills and behaviours must be understood within a broader organisational and system context. Interventions should extend beyond technical training to address emotional labour, relational dynamics and structural constraints. The COM-B and TDF frameworks provide a robust foundation for designing multi-component, context-sensitive interventions that reflect the realities of long-term care environments. Protocol registration Open Science Framework https://doi.org/10.17605/OSF.IO/STRKW Tweetable abstract ‘Mouth minutes’ matter. Poor oral care in care homes affects older adults' health & quality of life. Our theory informed scoping review maps barriers/enablers for oral care provision in this setting. It’s about more than technical skill #OralHealth #CareHomes #NICHELeeds @IJNS

Older adults are vulnerable to poor oral health due to physiological and cognitive changes, multiple medications, and dependence on carers. Despite national guidance, oral care in UK care homes remains inconsistent, and many staff report lacking the personal skills, organisational support, and confidence to deliver consistent oral care despite highlighting their commitment to deliver effective “mouth minutes” as part of daily routines. This study aims to examine care home and dental stakeholders’ views on supporting residents’ oral health, using the COM-B model to identify factors shaping staff oral-health-related behaviours. Focus groups were undertaken between June 2022 and November 2022 with the following 4 stakeholder groups to explore perspectives of supporting oral health maintenance in care home residents: (1) residents and relatives, (2) care home frontline workers, (3) care home managers and (4) external oral healthcare professionals (Oral HCPs) with care home experience. Framework analysis was undertaken at a semantic level and then matrices were mapped onto the COM-B model. Fifty participants from three care homes (residential and nursing homes), and external oral HCPs in Great Britain took part: 11 residents, 6 relatives, 25 care home staff (managers and frontline workers) and 8 external oral HCPs. Mapped against the COM-B framework; Opportunity, particularly Physical Environment, Context, and Resources, was the most frequently coded construct. There was also alignment with Capability, especially Behavioural Regulation and Skills, and within Motivation, beliefs about Consequences and Capabilities. Access to external oral healthcare professionals, tailored training, and organisational support were pivotal to improving oral health in care homes. The study confirms that micro‑level interventions are insufficient, as structural barriers—including limited dental access, workload pressures, and inconsistent resources—continue to undermine practice. Care home staff emphasised condition‑specific training and structured communication; relatives sought guidance to support loved ones; and external oral HCPs highlighted working and recognition of oral health as part of wellbeing. Aligning intervention design with the COM‑B framework provides a pathway to address structural, motivational, and capability barriers as interacting influences on oral care behaviour in care homes. This study explains why existing interventions fail by illustrating how Capability, Opportunity, and Motivation intersect, advancing COM‑B from a categorisation tool to an implementation‑focused framework.

Background/Aims Mouth care in care homes is a challenge. Existing evidence and behaviour change theory can be used to help improve mouth care outcomes. This article describes the final phase of a broader research initiative, the Caring Optimally: promoting effective Mouth MInuTes in care homes (COMMIT) study. The aim of this study was to develop a guiding principles resource to support care home staff with delivering mouth care. Methods Researchers with clinical (nursing and dental) and care home expertise drafted the guiding principles resource using mouth care evidence and behaviour change theory. Care home relatives and staff from care homes, dental and health sector settings (n=26) reviewed and developed the resource through taking part in online (n=4) and in-person (n=2) workshops. Results Participants feedback was used to develop and refine the guiding principles resource. Participants suggested additional ways of disseminating evidence and raised topics for further work in this area. Conclusions The guiding principles resource describes the capabilities, opportunities and motivation that care staff need to deliver mouth care. The resource has been developed collaboratively with the care home, dental/health sectors, is accessible and engaging, and available to download. Implications for practice At the care home level, there is a need to consider how the guiding principles resource can be integrated into existing systems, such as staff training programmes and digital care software. For instance, digital prompts could be used to remind staff which mouth care products to use, helping embed good practice into daily routines.

Background:Social care staff shortages are having a detrimental impact across the health and care system. There are reports of care homes closing, stopping nursing services and not admitting new residents because of challenges with staff shortages. Aim:To develop an explanatory framework of strategies used to attract, recruit, and retain registered nurses and care workers working in care homes. Explain how and why strategies work, for whom, the conditions needed and the costs involved. Design and methods:A realist synthesis approach was used. In step 1, strategies were identified and initial programme theories developed using data from stakeholder consultations (n = 10), theory gleaning interviews with registered nurses and care workers (n = 13), and evidence retrieved from scoping literature searches (n = 50). Strategies (and initial programme theories) prioritised by sector stakeholders focused on staff recruitment and retention, and were taken forward for testing/refinement. Step 2 involved searching academic databases and social care websites for evidence. Step 3 involved screening and selecting records relevant to the prioritised initial programme theories. Relevant data were extracted and analysed to identify context-mechanism-outcome configurations. To assess rigour, the appropriateness of research methods, and the plausibility/transparency of grey literature were assessed. Step 4 involved testing and refining the programme theories, with programme theories sense checked/refined by sector stakeholders. Existing and established theories were used to help further explain the programme theories and develop an overarching explanatory framework. Results:During step 1, strategies used to attract, recruit, and retain registered nurses and care workers were identified and initial programme theories developed (n = 22). Ten strategies and initial programme theories were prioritised for testing/refining and were focused on recruitment and retention: staff recognition, flexible working, career development, salary package, early investment, induction, continuous feedback, caring community, effective interviewing and listening to all staff. From the focused literature searches, 153 papers were included and data from these were used to test and refine the prioritised strategies and initial programme theories, and throughout the process collated into five final theories: effective interviewing, career development, reward and recognition, promoting work-life balance and caring conversations. These strategies do not operate independently; they interact and work together. Effective interviewing sets accurate expectations, and loyalty starts to develop through setting an accurate 'psychological contract' which is fulfilled over time. Opportunities for career development, rewarding and recognising staff, providing flexible working options and supporting staff with caring conversations help staff to feel listened to, respected and valued, which in turn, develops job satisfaction. Supportive leaders and a sense of inclusion and fairness are needed for these strategies to work. These strategies provide staff with positive experiences, and these are reciprocated through employee commitment and loyalty. Supporting staff through providing caring conversations and opportunities for career development also help staff feel empowered. Conclusions:This is the first realist synthesis in this field. The findings provide practical strategies for improving staff recruitment and retention. Limitations:Stakeholder consultations did not include the views of staff who had left care work. Future work:Understanding how to attract new staff to the social care workforce remains an important research gap. Study registration:This study is registered as PROSPERO CRD42021261112. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131016) and is published in full in Health and Social Care Delivery Research; Vol. 14, No. 21. See the NIHR Funding and Awards website for further award information.

Research in long-term residential care settings (or care homes) for older people should address questions and uncertainties that matter most for those receiving and delivering care. Whether research does this effectively is unclear. In part, because the uncertainties and questions of key stakeholders are unmapped. To capture and prioritise the uncertainties of older people living in care homes, their relatives and staff. A three-phase mixed-methods study: (i) gathering uncertainties, (ii) data analysis and (iii) prioritisation. Phase 1 used interviews to gather uncertainties from residents (n = 14), relatives (n = 10) and staff (n = 44). In phase 2, uncertainties were coded using thematic inductive analysis, represented as 'foreground' (necessitating research) or 'background' (not needing research) questions, and a prioritisation tool developed. The tool included optional open-text responses, capturing new questions fitting (and additional detail around) the existing subthemes. During phase 3, the prioritisation tool was completed by residents (n = 95), relatives (n = 85) and staff (n = 158). 319 uncertainties were identified: 274 foreground (research-based) and 45 background (fact-based) questions. Six broad and 38 subthemes were developed. Broad themes included (i) communal living, (ii) health and care services, (iii) resident care, (iv) residents' health and well-being, (v) residents' daily life and (vi) care home staff. Priority subthemes included enjoy living with others, dignity and respect, support with emotions, meaningful activities, and staff recruitment and retention. This is the first study of care home prioritised uncertainties informed by residents, relatives and staff. The uncertainty-based questions represent important targets for care home research and practice improvement.

Poor oral health is common among older people living in long-term residential care environments, or care homes. For decades, various strategies have been proposed to enhance and sustain oral health within this setting. However, implementation of these strategies and interventions has been variable, with limited positive impacts on long term oral health outcomes. The aim of this overview of reviews was to identify, appraise and synthesise systematic reviews of interventions or strategies provided by care home staff to support residents with their oral health. Protocol registration: PROSPERO (International Prospective Register of Systematic Reviews) registration ID: CRD42021293159. The search for systematic reviews was conducted in March 2025 in the following databases: Medline, Embase, CINAHL, PsycINFO and Epistemonikos. An analysis of overlapping primary studies within SRs was undertaken. Quality of reviews was assessed using AMSTAR2. Results were tabulated and a narrative synthesis was conducted. A total of 14 SRs were included. Most studies focused on training care staff to improve oral health knowledge and skills and just under half of included studies involved oral health care interventions testing protocols, such as regular mouth cleaning and structured regimens tailored to residents’ needs, some studies focused on resident care with dementia or cognitive impairments. Barriers to delivering oral health care were reported including time constraints, insufficient training, staff turnover, and resistance from residents. Suggestions to overcome such barriers were hands-on training to enhance staff confidence, tailored care plans for residents with impairments, managerial support for resource allocation, and fostering collaboration between care staff, family, and dental professionals. Evidence suggests that interventions are available to improve the oral health and care for this population, particularly around training of staff. However, the detail of the intervention was poorly documented. High-quality research is needed to determine which interventions benefit oral care for older people living in care homes.

Up to 60% of people living with dementia who reside in care homes will 'wander' at some point. A person-centred approach should be taken to support each person's individual needs through tailored interventions when wandering. This study aimed to identify care home staff perspectives on what supports safe wandering for people living with dementia in care home environments. As part of a larger study, and using a person-centred framework, semi-structured qualitative interviews were conducted with staff (N = 19) recruited from care homes in the North of England who provide care for older people. Transcripts were analysed using framework analysis. Four themes were identified, and two of these themes are presented here. Staff highlighted the importance of ensuring that personhood is at the centre of care delivery when supporting residents to wander. Clear leadership from management and meaningful involvement of families allowed staff to provide better support for residents. Staff also reflected on the importance of identification of unique impacts of dementia on each individual when providing person-centred care. The delicate balance between safety and well-being was consistently considered and reviewed. We identified a range of individual factors that contribute towards safe and supported wandering for people living with dementia. Positive risk taking, supported by policies and procedures, such as resident safety and meaningful activity, may allow staff to manage the benefits and risks associated with wandering.

Abstract Solutions for sustaining the social care workforce need to a) consider the different factors which influence staff experiences, b) recognize the nuances between different care settings, and c) differentiate between staff groups (e.g. age, levels of experience). At the University of Leeds, we led research which uses a realist synthesis approach to reviewing international academic and grey literature and contributions from sector stakeholders to develop theories. The results identified strategies used in care homes to attract, recruit, and retain Registered Nurses and care workers, e.g., effective job interviews, opportunities for career development, rewards and recognition, flexible working options, and caring conversations. The strategies used to attract, recruit, and retain staff do not operate independently, they interact and work together. We brought the evidence-based programme theories together into an explanatory framework to explain how and why these strategies work, for which staff, the conditions needed for strategies to work, and the outcomes to be expected. The framework summarizes the different ways the strategies help with attracting, recruiting and retaining staff. For example, empowering staff through caring conversations and opportunities for career development; building and fulfilling a psychological contract to set accurate expectations of care work; and reciprocating positive experiences (when providing staff with positive experiences staff will reciprocate and respond positively (i.e. commitment and loyalty at work). We will summarize the full findings during the symposium. To the best of our knowledge, this is the first time a realist synthesis approach has been used to review the literature in this area.

Background:Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence. Objective(s):To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers. Design:Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model. Setting:English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings. Participants:Managers, residents, families and care home staff. Findings:Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged. Limitations:Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes. Conclusions:Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes. Study registration:This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

ObjectivesUp to 60% of people with dementia living in care homes will 'wander' at some point, which has typically been seen by staff as a problematic behaviour. A range of non-pharmacological interventions have been tested to either support or prevent wandering. However, even recent innovative practice continues to maintain a focus on reducing or preventing wandering. This study aimed to identify, for the first time, care home staff perspectives on home level factors that facilitate or hinder them supporting residents to wander safely.MethodSemi-structured qualitative interviews were conducted with 19 care home staff, working in the North of England. Framework analysis was used to analyse the data.ResultsA range of environmental considerations were identified by staff. Care home design influenced how residents were able to move safely around, and inclusion of points of interest encouraged walking to different locations, such as a garden. Staff worried about managing access to other residents' rooms by people who wander. Within the care home culture, prioritising safe staffing levels, training and awareness, involving external healthcare professionals where required and mentorship from experienced staff members, all contributed towards safe wandering. Staff support for positive risk-taking within the care home was key to promote person-centred care, alongside careful oversight and management of relationships between residents.ConclusionWe identified a range of cultural and environmental factors that contribute towards safe wandering. A positive approach to risk-taking by staff is required to support residents to engage in wandering as an enjoyable activity, whilst acknowledging that there are inherent risks associated with this.

Abstract Background Science and care partnerships work on promoting quality of life, care and work in long-term-care (LTC) settings. The Scientific Linking Pin (SLP) is an academic employed by a university and works one day per week in a LTC organisation. The SLP role is pivotal to the success of partnerships; the nature of this role has not yet been captured. Methods Fifteen SLPs took part in semi-structured interviews. Data were thematically analysed. Results Data are presented over two themes. The first theme, the SLP experience, outlines that SLPs have rich insights into what matters to, and the challenges experienced in LTC organisations. SLPs are well positioned to impact practice, and develop their professional careers. SLPs do experience doubts and insecurities and require mentorship/supervision. The second theme, navigating in a SLP role, outlines the multifaceted tasks involved: relationship building, raising awareness, identifying priorities, generating research questions, building committees, brokering knowledge, developing research studies, generating academic output, building links and connections, and assisting with internal projects. The challenges SLPs face in their work include mistrust and poor engagement from care staff, working with staff from different professional backgrounds, research not being a priority, multiple and rapidly changing priorities, and differences in expectations. Relationship building, creating a ‘safe’ space for care staff, building engagement, and expectation management helped to address these challenges. Conclusion Partnership working in the care sector is gaining international recognition and adoption. This study described one key role that contributes to the success of the partnership model: the SLP.

Abstract Introduction and method Staff providing care to residents must manage uncertainties whilst using their judgement and making decisions about care. Residents and their relatives may also have questions and ideas about how care could be improved. It is important to capture uncertainties/questions and work on addressing these. We gathered uncertainties/questions from residents, relatives and staff before, and during COVID-19 through interviews, analysis of a COVID-19 WhatsApp discussion group for long-term-care (LTC), and a systematic literature review. Results Questions and uncertainties gathered were categorised into 21 themes: 1. Direct care (personal care, sleep, care planning, medication management, nutrition) 2. Physical environment (safety, mobility, infection risk) 3. Mental health/well-being (relationships, socialising and meaningful activities, spirituality) 4. Resident individuality and dignity 5. End-of-life 6. Quality of work for care staff (reward and recognition, training and career opportunities, well-being, shift flexibility, workload) 7. Staff shortages 8. Promoting staff diversity 9. Care home interaction with wider healthcare services 10. Use of technology 11. Family engagement and communication with staff 12. COVID-19-related anxiety 13. Financial support with care home costs 14. Care homes and climate change and future sustainability 15. Valuing the contribution of care homes 16. Infection prevention control 17. Visiting care homes during COVID-19 18. COVID-19 safety for residents and staff 19. COVID-19 and the individual (symptoms and treatment) 20. Organisational impact of COVID-19 21. Information sharing and learning from COVID-19. Discussion With LTC staff, residents and relatives the identified uncertainties/questions will be shortlisted; the prioritised list will direct future research.

Research has the potential to inform and enhance the care and experiences of people living and working in care homes. While there is a growing interest in research relevant for care homes, there is also a need to ensure that staff, residents and their families and friends are supported when considering taking part in research; particularly in a type of research called a ‘trial’. Trials are a type of research study that can help guide decisions about the best treatment, care and support for both residents (and their families and friends) and care home staff. While potentially important, trials are demanding for both care homes and trial research teams. Before agreeing to support a trial, there are questions a care home manager, staff, residents and their families and friends can consider. These questions are outlined in this article, and the answers to these will help a care home to determine whether they have the capacity, readiness and relationships to support a trial. By taking the time to ‘pause’ and ask ‘are we ready?’, care teams can support both care and science.

IntroductionInadequate and varied quality of care in care homes has led to a proliferation of quality improvement (QI) projects. This study examined the sustainability of interventions initiated by such projects.MethodThis qualitative study explored the sustainability of seven interventions initiated by three QI projects between 2016 and 2018 in UK care homes and explored the perceived influences to the sustainability of interventions. QI projects were followed up in 2019. Staff leading QI projects (n=9) and care home (n=21, from 13 care homes) and healthcare (n=2) staff took part in semi-structured interviews. Interventions were classified as sustained if the intervention was continued at the point of the study. Thematic analysis of interview data was performed, drawing on the Consolidated Framework for Sustainability (CFS), a 40-construct model of sustainability of interventions.ResultsThree interventions were sustained and four interventions were not. Seven themes described perceptions around what influenced sustainability: monitoring outcomes and regular check-in; access to replacement intervention materials; staff willingness to dedicate time and effort towards interventions; continuity of staff and thorough handover/inductions in place for new staff; ongoing communication and awareness raising; perceived effectiveness; and addressing care home priorities. All study themes fell within 18 of the 40 CFS constructs.DiscussionOur findings resonate with the CFS and are also consistent with implementation theories, suggesting sustainability is best addressed during implementation rather than treated as a separate process which follows implementation. Commissioning and funding QI projects should address these considerations early on, during implementation.

Abstract Introduction increasing demand for care, high staff turnover and low numbers of new staff are causing significant staff shortages in the long-term-care (LTC) sector. Solutions need to 1) take the heterogeneity of organisational and staff characteristics into account, and 2) make use of the large volume of literature describing the reasons staff join and stay in LTC work. Our research aimed to develop strategies which attract, recruit and retain Registered Nurses and frontline care workers in LTC; explain how and why strategies are effective, for which staff, the conditions needed, and the costs involved. Method This realist review involved (i) co-developing strategies and initial programme theories, (ii) systematically searching the evidence to test IPTs and develop theoretical propositions, and (iii) validating and refining propositions with stakeholder groups. Results IPTs around the following strategies were rated as important for attracting, recruiting and retaining staff in LTC, and taken forward to the testing phase of our review: rewarding and recognising staff, offering flexible working, career development opportunities, enhanced salary package, welcoming and inducting staff, listening to and providing staff feedback, developing caring work environments and effective staff interviewing. Leadership, caring cultures, teamwork, resources and adequate staffing levels are important conditions which enable these strategies lead to positive outcomes. Discussion this is the first study to use a realist approach to developing strategies focused on attracting, recruiting and retaining the LTC workforce. Our findings will be relevant at an international level. Acknowledgement: we thank Karen Winterburn and Edna Feenan for their important input throughout the project. They have both provided care home family perspectives, and have been involved throughout the development and execution of the project.

Context: The Living Lab in Ageing and Long-Term Care (Netherlands) and Nurturing Innovation in Care Homes Excellence in Leeds (NICHE-Leeds; UK) are partnerships between science and care. The Scientific Linking Pin (SLP), a senior researcher employed by a university, works one day per week in a LTC organization, and has a pivotal role in the partnership. Objective: To explore the nature of the SLP role Methods: A qualitative approach was used. Fifteen individuals with at least one year’s experience as a SLP in the Living Lab or NICHE-Leeds participated in a semi-structured interview. Data were thematically analyzed. Findings: Participants described how the SLP role gave them insight into what matters to care organizations, and how it enabled them to impact LTC practice. Participants experienced the role to be multifaceted. Goals and activities performed by SLPs included developing relationships, raising awareness of the practice-science partnership, identifying (research) priorities and generating research questions, building committees, brokering knowledge, developing research studies, generating academic output, building links and connections, and assisting with internal projects. Challenges faced were mistrust by care staff and poor engagement, working with staff from different professional backgrounds, research not being a priority, multiple and rapidly changing priorities, and differences in expectations. SLPs addressed these challenges through relationship building, creating a ‘safe’ space for care staff, building engagement, and expectation management. Implications: Partnership working in the care sector is gaining international recognition and adoption, and therefore it is useful to capture and share learning about successful implementation of our approach.

COVID-19 had a devastating impact on older people living in care homes. This study explored the clinical trajectory and management of COVID-19, as well as recovery of older people following infection during the early stages of the pandemic (May to August 2020). A two-phase exploratory qualitative study was used. Frontline staff with experience of caring for older people with COVID-19 were recruited to Phase 1, and senior care home operational and quality managers were recruited to Phase 2. During Phase 1 remote semi-structured interviews (n = 35) were carried out with staff working in care homes, hospital and community settings in England. During Phase 2, a remote consultation event was carried out with senior care home operational and quality managers (n = 11) to share Phase 1 findings and check resonance, relevance and gaps. Data were analysed using Framework Analysis. Older people with COVID-19 presented with wide ranging symptoms, and an unpredictable illness trajectory. The wide range of COVID-19 symptoms required timely testing and supportive interventions. Staff used different interventions to manage symptoms and reported uncertainties of how individuals would respond. In care home settings, health and social care staff needed to work together when administering interventions such as subcutaneous fluids or oxygen therapy. Alongside symptom management, supportive care focused on nutrition and hydration, social interaction, and maintaining physical activity to meet both physical and emotional needs. The effects of prolonged periods of social isolation and inactivity on the health and well-being of older people means rehabilitation is essential to enhance physical and emotional recovery, and to minimise impacts on cognition and function. The pandemic highlighted important areas for care of this population.