Hodge, Sevim Yasemin
(2025)
Recognising and responding to acute deterioration in care home residents. a mixed-methods study.
PhD thesis, University of Nottingham.
Abstract
Background:
Older adults living in care homes are among some of the frailest and most vulnerable in society. Often living with multiple long-term conditions (MLTC), frailty, sarcopenia and age-related changes to immunity means they are at greater risk of becoming unwell and acutely deteriorating. Early recognition and response to acute deterioration is associated with better prognosis and clinical outcomes. However, much of the evidence has emerged from studies conducted in younger population cohorts. Further, initiatives to support identifying and managing this condition in older adults are based on practices adopted from acute inpatient hospital settings. There is a shortage of research on what acute deterioration means for older adults living in care homes and little is known about how care home staff recognise and respond to acute deterioration in residents.
Aims:
The studies in this thesis aimed to understand acute deterioration from the perspectives of care home staff. Specifically, to establish usual practice, explore how care home staff recognise and respond to acute deterioration in residents and identify the barriers and facilitators of this condition to inform future recommendations regarding this aspect of care.
Method
A concurrent mixed-methods design was used to gain a comprehensive understanding of acute deterioration in care homes from the perspective of care home staff. Four work packages were conducted. A scoping review sourced the available evidence regarding acute deterioration in care homes. A care home survey was conducted to establish usual acute deterioration practices in English care homes. Semi-structured interviews were conducted with care home staff to better understand acute deterioration from their perspectives and finally, a Nominal Group Technique (NGT) was conducted with care home staff and topic experts to establish agreed priorities for identifying and managing acute deterioration in care home residents.
Results:
The scoping review included n=11 journal articles. Findings evidenced the concept of acute deterioration was poorly defined. The studies showed acute deterioration was captured tangentially – in relation to other aspects of care and not as the main phenomenon of interest. There were multiple interrelated factors within and external to the care home that influenced how this condition was managed
The survey yielded n=146 responses from fourteen different geographical regions of England. Most responses came from staff aged ≥25 years (95.9%). Just under half of survey responses were from managers (44.5%). The survey identified four acute deterioration tools being used in care homes – NEWS2 (34.2%), RESTORE2 (23.3%), Significant 7 (6.2%) and Stop & Watch (11%). Just over a fifth (21.9%) of responses stated no acute deterioration tool was in use. Respondents were asked to rank their confidence levels in escalating concerns about a resident to different healthcare professionals and services such as GPs. Overall, most respondents selected ‘very confident’ Similarly, respondents who reported not using a tool were asked their confidence levels in escalating their concerns. The majority of responses were also ‘very confident’.
Semi-structured interviews were conducted with twenty care home staff including: registered nurses, care assistants and managers. The findings showed acute deterioration was difficult for staff to define and encompassed different levels of deterioration. However, the relationships staff had with residents enabled them to identify acute deterioration. Findings also highlighted how acute deterioration tools such as NEWS2 and RESTORE2 were boundary objects. Care home staff used them as they provided a universal language to communicate concerns about a resident to external healthcare professionals. Further, some of the findings illuminated potential risks associated with using these tools. Specifically, potential delays in treating acute deterioration because of a mismatch between care home staff’s assessments of residents (indicated deterioration) and clinical indicators (vital signs) not triggering a response.
The Nominal Group Technique NGT brought together an expert panel of experienced care home staff (registered nurses, care assistants and care home managers) and academic/topic experts. The panel co-produced n=31 agreed priorities on what was important to identify acute deterioration, what was important to handover, and what was needed to manage acute deterioration. The top priorities from each round were ‘physical signs and symptoms’, ‘changes in physical symptoms’ and ‘adequate staffing levels’. The agreed priorities offer valuable insights into the needs of care homes to manage acute deterioration and raised important questions about service user needs and the necessary provisions required to support care home residents.
Conclusion:
This thesis has provided a contextual understanding and overview of acute deterioration in care homes from the perspectives of care home staff. This viewpoint was underrepresented in the current body of evidence. The findings from this PhD have helped to bridge this knowledge gap. This thesis lays the foundation for future research on acute deterioration, focusing on establishing appropriate escalation responses and developing frailty-specific strategies for managing and responding to residents' needs. To achieve this, co-production approaches and the involvement of key collaborators (e.g. care home staff and GPs) working together is needed.
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