Title: Improving skills and care standards in the clinical support workforce: a realist synthesis of workforce development interventions
Funder: Division for Social Care and Health Research (Wales)

Abstract: BackgroundThe NHS is under pressure to develop new service models processes roles and expertise in the care of older people. One in five people are estimated to be aged over 65 by 2033 (Wise 2010) while 70% of the health budget is spent on those over 65 (Oliver 2010). Long term conditions afflicting older people may be associated with specific needs around communication and cognition which will shape the design of care interventions. However NHS care standards have been criticised (CQC 2011; Parliamentary and Health Service Ombudsman 2011) while others accuse services of ‘ageist’ practices and attitudes (Tadd et al. 2011). Assistant care workers support the work of the regulated professional workforce in their day to day duties. However present use and development of assistant care workers has been somewhat ad hoc with a range of practices and approaches adopted due to the various roles performed (Nancarrow et al. 2010) and differences between NHS trusts (Spilsbury et al. 2009). These workers have also become an undervalued resource (Schneider et al. 2010). This review will fill a gap in the evidence by identifying the interventions that enhance the skills and care standards in the clinical support workforce for older people. We are specifically interested in uncovering how and why these interventions may impact and on whom.Review question & aimsHow can workforce development interventions improve skills and care standards of clinical support workers within older people’s health services?1. Identify support worker development interventions from different public services and to synthesise evidence of impact.2. Identify the mechanisms through which these interventions deliver support workforce and organisational improvements to benefit the care of older people.3. Investigate the contextual characteristics that mediate the potential impact of these mechanisms on clinical care standards for older people.4. Develop an explanatory framework that synthesises review findings of relevance to services delivering care to older people.5. Recommend improvements for the design and implementation of workforce development interventions for clinical support workers. ApproachWe will undertake a realist synthesis to address this question and aims Realist enquiry is based on causal and contingent explanations that identify underlying attributes contributing to a particular outcome in a number of specific (but not identical) phenomena. As workforce development is context dependent and complex a realist review will facilitate an understanding of how different workforce interventions may work in different settings to result in impacts/outcomes.Our realist synthesis will be conducted in four phases over 18 months:Phase 1: Programme theory developmentWe will construct a theoretical framework i.e. the reviews programme theory from the underpinning literature on learning and workforce development and in consultation with stakeholders. The framework will provide a provisional explanation of the impact of interventions by bringing together separate but interlinked disciplines each with their own literature theory and approaches. These include:- Learning & role progression – the professional development from novice to expert (eg Dreyfus & Dreyfus 1980 1985)- Multiple levels of intervention learning & role progression - connections between different interventions and functions being performed (e.g. Pratt et al 1999)- Learning theory and theories of adult learning - how individuals learn new processes and ideas (e.g. Bloom 1956; Kolb 1984)- Workforce behaviour change – the transitions between knowledge and practice (e.g. Michie et al 2009; Prochaska & DiClemente 1982)- Organisational & other contextual influences – structural factors affecting the implementation of learning and practices (e.g. Easterby-Smith 1997; Raelin 1997)Phase 2: Retrieval review and synthesisGuided by the programme theory/theories we will search for relevant research related to interventions for developing assistant care workers. Initially we will target health and social care services specific to older people and then expand our search to evidence from workforce development interventions in related fields that use assistant workers (police and education). Finally we will refine our search across generalist health services that may be accessed by older people (eg primary care general practice) which may be limited to those services providing ‘first point of contact’ depending on views from our stakeholder group.The review process will involve screening for relevance data extraction and charting to identify what appears to work for whom how and in what contexts.Phase 3: Testing and refining programme theoryWe will draw on the input of various stakeholders including patients managers policy makers practitioners and researchers to test out our synthesis findings and refine the programme theory/ies and to establish their practical relevance/potential.Phase 4: Actionable recommendationsWe will use our synthesis findings to formulate recommendations about improvements to current workforce development interventions. These may include:- Helping develop interventions with multiple impacts and outcomes for the workforce older people organisations and policy- Creating possible synergy between personal / career aspirations and intervention provision- Understanding the cognitive attitudinal and instrumental impacts of interventions.Working with relevant stakeholders we will tailor our outputs towards managers (in the NHS and beyond) patients assistant care workers and their colleagues can use them to improve existing practices.Benefits to the NHSThe increasing pressures to provide effective health and social care for older people will be an enduring concern for the NHS. By presenting a series of improvements for interventions to develop assistant care workers this review will provide evidence for the NHS to meet these demands and to increase the potential to deliver better quality care.The team is ideally placed to carry out this review being experts in health social care justice and older people research implementation/service improvement realist synthesis and patient and public involvement. The research team will be supported by a steering group and advised by stakeholders including PPI.


Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE