Evidence-based practice (EBP) in nursing involves the collection, processing, and implementation of research findings on a given subject to develop clinical practice. Using evidence-based practices in nursing helps deliver the highest quality care at a relatively lower cost (Lawton et al., 2015 p113). Clinicians use the PICO system to identify the clinical needs of patients. The PICO system identifies a clinical problem by focusing on the four dimensions of Population (P), Interventions (I), Comparison (C), and Outcome (O) of an evidence-based problem. This study seeks to examine the nursing profession in regard to obesity and establish the areas that need improvement in dealing with obesity. In addition, the CASP framework helped within the current research to identify whether the literature was of use. The CASP framework asks whether the literature being examined meets the following criteria:
- Are the results of the study valid?
- What are the results?
- Will the results help locally?
Literature chosen for inclusion in this essay was expected to meet the above criteria. In doing so, this research helped to effectively address the PICO question. The PICO question itself was established to guide the research.
Home care in the United Kingdom is known by several different names, including domiciliary care, homecare, and home help (NHS 2019). This type of care is delivered within the home typically at a rate of £20 an hour, though the costs will vary depending on where a person lives. The degree to which a person may need care will vary, with some people requiring care for only an hour while others require care over several hours or days. At times, people may require someone to live in the home with them. Recent concerns about the quality of care delivered using domiciliary care have arisen due to time pressures placed on care workers (Atkinson and Crozier 2016; Gethin-Jones 2017; HSCIC 2013). The constant attention to time as a limitation on the quality of care and the opinion that home care was not of the best quality, as identified in the literature, led to the development of the following PICO question:
Does home care service as currently designed meet the needs of service users from the perspectives of those involved?
The current research attempts to address this question by identifying existing literature regarding the care delivered in domiciliary care. How the delivery of care is impacted by pressures, particularly pressure to complete specific duties within a given timeframe, is of concern. This research attempts to address whether quality is impacted and discuss how practice may be enhanced in order to deliver higher quality care.
According to the HSCIC (2013) 1.9 billion is spent on home care. Domiciliary care is often commissioned by using a ‘time and task’ approach. Using this approach, the delivery of home care services is fit into a short time frame. Domiciliary care providers focus solely on completing their assigned tasks during this time. There is evidence from both service users and home care workers that the demands of ‘time and task’ by local authorities leads to a lack of flexibility in the delivery of home care service. Home care workers are left unable to manage their time in a way that satisfies service users and are unable to help with additional tasks outside the scope that they’ve been assigned. A previous research survey reported that 73% of local authority funded home care visits in England last just 30 minutes (UKHCA 2013). Potentially problematic was the fact that within the same survey, domiciliary care provider suggested that 16% of home care visits lasted only 15 minutes. The quality of care potentially dropped due to the fact that a phenomenon known as ‘call cramming,’ in which care workers were forced to visit too many sites too quickly (HSCIC 2013). This created a situation in which worker were unable to deliver the quality of care that they might otherwise want to deliver. As suggested within the current research, there were also additional problems that impacted the quality of care related to time and pay (Atkinson and Crozer 2016).
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Time and the ability to allot time to a service user is of critical concern. Domiciliary care requires significant time management skills because how a care worker uses their time is one of the primary means by which the work is assessed within ‘time and task’ framework (HSCIC 2013). However, this potentially places ‘time and task’ at odds with the relationship that care workers have with service users. The worker may be unable to attend to other tasks or demonstrate care for the service user. In social care, if the service user is not actively engaged with the care worker in a trusting relationship, the particular needs of the service user may not be identified (Aronson and Neysmith ,1996; Needham 2009). A care worker exclusively focused on meeting their duties under ‘time and task’ may not be able to create that relationship and identify additional needs of the service user.
Two articles were chosen that highlighted the problem of quality in home care, with each article identified using online science databases to search for topics related to home care quality in the UK. Qualitative investigation into the care delivered by domiciliary workers suggested that poor care became a reality among care workers. Researcher examined working time practices in Wales using focus groups and interviews (Atkinson and Crozier 2016). Discussions with care workers indicated that the amount of working time set aside negatively impacted the job satisfaction for these workers and negatively impacted recruitment and retention of new workers. Along with this dissatisfaction came a drop in the level of care quality provided.
Three major reasons were identified that indicated why there were negative outcomes for care workers and the quality of care delivered. These problems included zero-hour contracts, episodic working, and short service visits. Zero-hour contracts were contracts in which employers and workers were not obliged to accept work. Episodic working was work in which care workers were not paid for wait time between visits or traveling time between visits. Finally, the inability to provide longer periods of care negatively impacted both the worker and service user.
The researchers pointed to time as a recurring issue that negatively impacted workers, and specifically cited fragmented time as a source of issues. Care workers themselves experienced employment insecurity from both zero-hour contracts and episodic working (Atkinson and Crozier 2016). Care workers were not guaranteed a certain amount of hours of work and could lose hours if a service user went into the hospital and did not need care for that week. When they did have work, care workers had gaps in their visit schedules. Care workers only received payment for contact time only, which led to significant unpaid periods. Care service employers suggested that this was a phenomenon beyond their control due to a limited budget.
Compounded the general problems of employment was the ongoing recurrence of short visits. Care workers noted that short visits were not uncommon and placed them under tremendous stress (Atkinson and Crozier 2016). Care workers indicated that even running late by a minute or two meant that they then had to fit in all of their tasks within an even smaller timeframe. When taken together, the issue of zero-contract work, episodic work, and extremely short time frames within which to visit clients compounded to create exhausted workers who delivered lower quality care.
The phenomenon of lower quality care was gauged from the user perspective. Service users felt that there was a lack of reliability, continuity, and flexibility among the care workers who provided services (Atkinson and Crozier 2016). The nature of fragmented work meant that care givers often arrived late, if at all, and had to compress their duties within an already limited timeframe. Inadequate time to provide flexible care was not uncommon, and care workers demonstrated a lack of enthusiasm and motivation in their duties. In practice, workers were expected to travel rapidly from one site to another in order to arrive on time, but slight delays at one site would compound over time, leaving workers constantly struggling to catch up. The quality of care provided declined for multiple reasons. Care workers lacked motivation, but this lack of motivation largely stemmed from poor working conditions, and they often lacked the time to provide truly flexible care to a service user.
Separate research suggested that the model and manner in which homecare was delivered had an impact on the quality of care delivered. Researchers examined home care delivery and the relationship between home care workers and older persons in an attempt to identify how the quality of care could be improved despite working within a ‘time and task’ framework (Gethin-Jones 2017). The researchers found that there were three ways in which care could be improved. Social interactions, consistent care staff, and granting increased control to patients all impacted outcomes.
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Participants in the study indicated that they felt treated like animals. Care givers would rush in to complete a task and rush out again without saying much, dehumanizing the individuals they were working with (Gethin-Jones 2017). Participants compared it to changing the litter for a pet animal. Within the context of the study, care givers who were given more time increased their connections with their service users. Personal information was exchanged and service users began to feel a sense of connection with their care givers. It was important for care givers to try to personalize the service that they were giving rather than rushing through their duties.
Related to the concept of personalization was the need for consistency. Service users required a consistent care staff that could work with them rather than a constant change in staff (Gethin-Jones 2017). All service users interviewed indicated that they needed consistency in order to form a relationship with caregivers. Otherwise, care giving tended to be impersonal. Service users emphasized how personal the care was that they received .Care givers had to perform duties that were quite intimate. As such, service users benefited when they had a consistent staff that they could connect with over time. This made the services provided less intrusive.
The final finding of the study indicated that patient enjoyed feeling as if thy had a sense of control in their care. This finding was less connected to some of the other findings in the literature but still suggested a way of improving the quality of care delivered even within a restricted time frame (Gethin-Jones 2017). Service users enjoyed being provided with care that they had a say in. Once again, in interviews, service users emphasized the personal quality of the care that was being delivered. The researchers noted that communication was important between the care giver and the service user, indicating that regardless of the timeframe within which work needed to be done, care givers could enhance the quality of care by communicating with the patients.
Two articles were chosen for inclusion in this research which attempted to determine if the care given in home care was adequate from the perspective of the users themselves. The first article reviewed issues in the delivery of home care using a qualitative investigatory approach (Atkinson-Crozier 2016). This study was consistent with the larger PICO question in that it examined a part of the population involved in the caregiving relationship.
This first article studied the care givers themselves. With regard to whether the results were valid, the researchers did not attempt to identify an intervention and did not produce quantitative data with results that could be questioned regarding validity. However, the interview analysis conducted between participants however seemed to reveal commonalities between multiple participants. The study was designed around identifying themes common to the participants and seemed to produce valid qualitative results. These results met the secret criteria of CASP, namely producing identifiable results that could be used to answer the researchers questions. The researchers set out to determine what factors impacted the quality of care given, revealing three primary contributors to declining quality care. These contributors included zero-hour contracts, episodic work, and short time frame within which to provide care. The findings of the study directly contributed to the current paper, given the purpose of this paper to examine whether home care service as designed met the needs of service users. The answer would seem to be no. Care givers are limited in the quality of care that they can deliver (Atkinson-Crozier 2016). Because of budgetary concerns, employers cannot guarantee hours to employed care provides and cannot ensure daily schedules that won’t be sporadic in nature. When care givers do arrive, due to the same budgetary constraints, they are expected to complete a specific number of duties within a limited time. As a result, it would seem that the quality of home care delivered is not adequate, largely because of how budget constraints affect employment type and time committed to service users.
The second article took a similar qualitative approach, which was consistent with this paper’s emphasis on understanding the perspectives of those involved. In the second article, the interviews conducted were from the perspectives of service users (Gethin-Jones 2017). Regarding the validity of the findings, the researchers used interviews conducted among 16 service users. Findings were supplemented with follow up interviews to help check the validity of the researcher’s findings. Care givers delivered care in one of several different ways to help researchers identify differences in outcomes as gauged from the perspectives of those receiving the care. The process included a semi-structured interview before a care intervention was provided, an observation of care givers using the care intervention, and a follow up interview to close work with one of the service users. The qualitative data was valid in that researchers searched for commonalities between participants using a thematic analysis. Conclusions were not drawn without ensuring the responses were common to the majority of participants. The findings of the study were important to the current paper because they highlighted the perspectives of those involved with caregiving, except this time from the perspective of the service users. These users suggested that care was often inadequate and suggested that more social interaction was needed using a consistent staff that was comfortable with personalizing care to the service user. The findings were of important to the current study because they indicated that the quality of care was not adequate while also suggesting ways in which it could be improved.
A synthesis of both the background information presented in this paper and the two articles highlighted for the critical literature suggests that home care is not adequate from the perspectives of both care givers and service users but that there may be a way of improving the quality of care provided. The primary problem occurring in the home care issue involves time, and that problem manifests in multiple ways in the home care field. On the care providers side, there are often not enough hours for them to work due to the types of contracts they operate under, and when there are hours available, the schedule requires constant rushing. Care providers must rush from one home to the next with even slight delays resulting in an ongoing attempt to catch up with work. Delays impact care delivery at a service user’s home, where existing requirements insist that care givers stick to only providing a certain set of services and delivering those services within a specific timeframe. This method of delivering care is known as ‘time and task,’ and it leads to workers who feel burned out and service users who feel uncared for. This feeling that one is uncared for was exemplified in interviews with service users who compared their treatment to that of animals, with caregivers rushing to complete the tasks they were required to do and demonstrating little flexibility to provide additional care or connect with the service users.
The answers that emerged from the literature indicated that improving care was partly rooted in administrative changes and partly rooted in caregiver approaches. Employers indicated that the reason for ‘time and task’ approaches were budgetary in nature. For these same reasons, care workers could not be provided with regular hours and a consistent schedule. So, one of the initial changes that would seem to be necessary may include increasing budgets for these services. However, this kind of change would require a shift in how payments are made to employing agencies. Given that councils sometimes pay partly for the delivery of services, how they financially support home care may also need to be adjusted. The issues of budgets speak to a larger concern about how home care in the UK is handled and funded.
The only other solution to arrive from the literature was the concept of increasing the personalization of care and consistency of staff. Again, this speaks to a budgetary issue. Budgets shaped schedule and how care givers were scheduled, but the pressures led to turnover that could negatively impact scheduling. Employers needed to take steps toward maintaining consistent schedules that did not include rushed appointments between sites. This would help reduce the amount of stress felt by care givers and reduce turnover, increasing the consistency in staffing. However, a second benefit that might arise from consistency would be the ability for caregivers to personalize and connect with service users.
Personalizing seemed to emerge as a means of increasing the quality of care that service users desired and should be something that care givers attempt no matter how much they time are limited to. Even when there isn’t enough time to provide other care, they should try to provide some small level of personal connection that makes a service user feel comfortable. In truth, it is the duty of employers to schedule care givers in such a way that they are able to provide these small, personal touches. To bet enhance the practice of home care givers, fundamental changes have to occur among employers and the way they contract and schedule care giving employees.
- Atkinson, C. and Crozier, S., 2016, December. Fragmented time and domiciliary care quality:‘no-one sets out to provide bad care but you’re dragged to it, dragged into the gutter’. In CIPD applied research conference: The shifting landscape of work and working lives, University of Westminster, London (Vol. 19).
- Gethin-Jones, S., 2017. A Participant Observation of the Delivery of Home Care Services to Frail Socially Isolated Older People Receiving Two Different Models of Care Delivery. J Gerontol Geriatr Res, 6(396), p.2.
- “Help at Home from a Carer.” NHS Choices, NHS, 2019, www.nhs.uk/conditions/social-care-and-support-guide/care-services-equipment-and-care-homes/homecare/.
- Neysmith, S. and Aronson, J. (1996). Home care workers discuss their work: The skills required to “use your common sense.” Journal of Aging Studies, 10 (1), pp. 1-14. (Accessed 14.08.19).
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