YSGOL GWYDDORAU GOFAL IECHYD / SCHOOL OF HEALTHCARE SCIENCES PRIFYSGOL BANGOR / BANGOR UNIVERSITY Improving skills and care standards for the support workforce in health and social care services for older people: a realist synthesis of evidence Jo Rycroft-Malone, Christopher R. Burton, Lynne Williams, Stephen Edwards, Denise Fisher, Beth Hall, Brendan McCormack, Sandra Nutley, Diane Seddon, Roger Williams Gwella medrau a safonau gofal ar gyfer y gweithlu cefnogi mewn gwasanaethau gofal iechyd a gofal cymdeithasol i bobl hyn; cyfosodiad realistaidd o dystiolaeth

PRIFYSGOL BANGOR / BANGOR UNIVERSITY Nid oes gan y cyflwynwyr unrhyw fuddiannau croes i’w datgan. The presenters have no conflicts of interest to declare. Datganiad yr Awdur Authors’ declaration Cefnogir y gwaith gan Raglen y Sefydliad Cenedlaethol dros Ymchwil Iechyd (NIHR) HS a DR, Rhof Grant 12/129/32. Mae’r adroddiad hwn yn cyflwyno ymchwil annibynnol a gyllidwyd gan y Sefydliad Cenedlaethol dros Ymchwil Iechyd (NIHR). Safbwyntiau a barn yr awduron yw’r rhai a fynegir yn y cyhoeddiad hwn, ac nid ydynt o anghenraid yn adlewyrchu rhai’r GIG, NIHR, y rhaglen HS a DR na’r Adran Iechyd. Os oes dyfyniadau gair-am-air wedi’u cynnwys yn y cyhoeddiad hwn, safbwyntiau barn y rhai a gyfwelwyd sydd wedi’u nodi, ac nid ydynt o anghenraid yn adlewyrchu rhai’r awduron na rhai’n GIG, NIHR, y rhaglen HS a DR na’r Adran Iechyd.

Golwg ar ofal Iechyd pobl hŷn Spotlight on older people’s care

Y gweithlu cefnogi The support workforce The support workforce delivers care alongside the regulated, professional workforce in their day to day duties under supervision (SDO Network, 2011) Roles vary across health and social care services, from healthcare assistants and support workers (Cavendish, 2013), healthcare support workforce (HEE, 2014), care assistants or therapy assistants (Moran et al, 2014) Support workers can act as an additional resource to enhance older people’s experiences by improving the contact with care practitioners (Wakefield et al, 2009: Nancarrow et al, 2010) Mae aelodau’r gweithlu cefnogi’n darparu gofal ochr yn ochr â’r gweithlu proffesiynol rheoledig yn eu dyletswyddau beunyddiol dan oruchwyliaeth (Rhwydwaith SDO, 2011) Mae swyddogaethau’n amrywio ar draws gwasanaethau iechyd a gofal cymdeithasol, yn gynorthwywyr gofal iechyd a gweithwyr cefnogol (Cavendish, 2013), yn weithlu cefnogi gofal iechyd (HEE, 2014), yn gynorthwywyr gofal neu’n gynorthwywyr therapi (Moran et al, 2014) Gall gweithwyr cefnogi weithredu fel adnodd ychwanegol i wella profiadau pobl hŷn trwy wella’r cyswllt ag ymarferwyr gofal (Wakefield et al, 2009: Nancarrow et al, 2010)

Y gweithlu cefnogi – problemau a blaenoriaethau The support workforce –issues and priorities Evidence shows that support workers are not used as effectively as possible and are often undervalued (Kessler et al, 2010: Schneider et al,2010) Greater use and development of the support workforce in health and social care a long term priority for NHS managers and other sector organisations Urgent need to improve the skills and training approaches currently used to develop support workers (Care Quality Commission, 2011; Skills for Care, 2011) Tystiolaeth yn dangos na ddefnyddir gweithwyr cefnogi mor effeithiol ag y gellid, a chânt eu tanbrisio’n aml (Kessler et al, 2010: Schneider et al,2010) Mae gwneud mwy o ddefnydd ar y gweithlu cefnogi mewn iechyd a gofal cymdeithasol a datblygu’r gweithlu’n well yn flaenoriaeth dymor hir ar gyfer reolwyr y GIG a sefydliadau eraill o fewn y sector Mae angen brys i wella’r dulliau presennol o roi medrau a hyfforddiant er mwyn datblygu gweithwyr cefnogi (Comisiwn Ansawdd Gofal, 2011; Medrau ar gyfer Gofal, 2011)

Cyfosodiad Realistaidd? A Realist Synthesis? Strategy for synthesising evidence which assumes that complex interventions like workforce development ‘play out’ differently for different people and in different settings Increasingly popular approach for answering questions about “what happens” (i.e. for this review, not whether workforce development works) and why Contingencies explain the relationships between changes in participants’ thinking, resources or behaviours (the ‘what happens’ - mechanisms) in different conditions (context), and the outcomes of workforce development Strategaeth i synthesu tystiolaeth sy’n cymryd bod ymyriadau cymhleth, megis datblygu gweithlu, yn digwydd yn wahanol yn achos pobl wahanol ac mewn sefyllfaoedd gwahanol. mae’n ddull mwyfwy poblogaidd o ateb cwestiynau am “beth sy’n digwydd” (h.y. yng nghyswllt yr adolygiad hwn, nid p’un a yw datblygu’r gweithlu’n gweithio) mae posibiliadau’n egluro’r cysylltiad a geir rhwng newidiadau yn y ffordd y mae cyfranogwyr yn meddwl, eu hadnoddau neu eu hymddygiadau (mecanweithiau ‘beth sy’n digwydd’) dan amodau gwahanol (cyd- destun), a chanlyniadau datblygu’r gweithlu.

Egwyddorion ymholi realistaidd Principles of realist enquiry Mae rhaglenni’n ‘theorïau’ Mae rhaglenni wedi’u ‘sefydlu’ Mae rhaglenni’n ‘weithredol’ Programmes are ‘theories’ Programmes are ‘embedded’ Programmes are ‘active’ M ODERNEIDDIO A D ATBLYGU ’ R G WEITHLU

Theorïau a fynegir yn aml fel: cyd-destun-mecanwaith-deilliant (CMD) Theories often expressed as: Context + Mechanism=Outcome (CMO) CONTEXT Features of participants, organisation, culture, history etc. that are required to ‘trigger’ or fire a mechanism MECHANISM* How do the programme resources impinge on stakeholders’ reasoning/decision making – their response OUTCOME Different behaviour(s)– short… medium… longer term *Operate at different levels of reality, cannot usually be directly observed, whether they fire or not depends on the context CYD-DESTUN Nodweddion cyfranogwyr, sefydliad, diwylliant, hanes ayyb sy’n ofynnol er mwyn sbarduno neu ysgogi mecanwaith MECANWAITH* Sut y mae adnoddau’r rhaglen yn cyfyngu ar allu budd- ddeiliaid i resymu/ cymryd penderfyniadau – eu hymateb DEILLIANT Gwahanol ymddygiad(au) – tymor byr, canolig, hwy

Cwestiynau ac amcanion ymchwil – Research question Sut y gall ymyriadau i ddatblygu’r gweithlu wella medrau a safonau gofal ymysg gweithwyr cefnogi o fewn gwasanaethau iechyd pobl hŷn? How can workforce development interventions improve skills and care standards of support workers within older people’s health services?

Datblygu theori’r rhaglen Dadansoddi budd-ddeiliaid Gweithdy adeiladu theorïau Cyhoeddi protocol Cam / Phase 1 Cam / Phase 2 Cam/ Phase 4 Cam/ Phase 3 Strategaeth chwilio Proses chwilio Tynnu data allan Casglu, dadansoddi/cyfosod data Byddino gwybodaeth Argymhellion y gellir gweithredu arnynt Adrodd/ Cyhoeddi Proses cyfosod Profi cyd-destunau – mecanweithiau – deilliannau Cyfweld ar y ffôn The Process (over 18 months) Y broses (dros 18 mis)

Datblygu theori’r rhaglen Developing the programme theory Tynnu data allan/ Data extraction datblygu ffurflenni unigryw ar gyfer casglu data unique data extraction forms Theorïau cyntaf y rhaglen gyntaf i dynnu “tameidiau” o ddata allan initial programme theories to guide extraction of “nuggets” of data Dadansoddi a Chyfosod Analysis & Synthesis trefnu’r data a gasglwyd yn dablau tystiolaeth yn dangos y pedwar maes theori o theorïau’r rhaglen gyntaf extracted data organised into evidence tables representing the four theory areas from the initial programme theories. trefnu’r data yn dablau tystiolaeth yn dangos continwwm yn amrywio o effaith gysyniadol (ymwybyddiaeth, gwybodaeth a dealltwriaeth) at y cyfryngol (ymarweddiadau a dirnadaethau) hyd at effaith uniongyrchol (newid ymarferol) extracted data organised into evidence tables representing a continuum ranging from conceptual (awareness, knowledge and understanding) to instrumental( attitudes and perceptions) to direct impact (practice change) Cyfosod/ Synthesis edrych am batrymau yn y data i egluro gosodiadau ‘os... yna’ ynglŷn â’r hyn a allai weithio, i bwy, sut, ac ym mha amgylchiadau, ynglŷn ag ymyriadau yn natblygiad y gweithlu ar gyfer y gweithwyr cefnogi (damcaniaeth gredadwy) looked for patterns in the data to explain ‘if…then’ statements about what might work, for whom, how, why and in what circumstances about workforce development interventions for the support workforce (plausible hypotheses) datblygwyd naratif amodol yng nghyswllt pob damcaniaeth, fel bod modd canfod cyfluniadau cyd- destun-mecanwaith-deilliant a contingent narrative was developed around each hypotheses, which enabled the uncovering of context-mechanism-outcome configurations

Canfyddiadau -y C-M-D Findings –the C-M-Os “Ei wneud yn real” i waith y gweithiwr cefnogi fel unigolyn O ble mae’r gweithiwr cefnogi “yn dod” Deall cymhellion gweithwyr cefnogi Cyd-gynllunio Cysylltu pethau yng nghyd-destun datblygu’r gweithlu “Cyd-deithio” Defnyddio dull bwriadus wrth ddatblygu’r gweithlu Lledaenu effeithiau’r gwaith o ddatblygu’r gweithlu “Making it real” to the work of the individual support worker Where the support worker is “coming from” Tapping into support workers’ motivations Joining things up around workforce development Co-design “Journeying together” Taking a planned approach in workforce development Spreading the impacts of workforce development

“Making it real” to the work of the individual support worker “ Ei wneud yn real” i waith y gweithiwr cefnogi fel unigolyn If intervention design and delivery is close to the work of the support worker (Context) this prompts resonance with individuals participating in it (Mechanism) which can result in cognitive and practice changes in them (Outcome)

Where the support worker is “coming from” O ble mae’r gweithiwr cefnogi “yn dod” If workforce design and delivery pays attention to the individual support worker’s personal starting points and expectations of the role (Context) this prompts better engagement with the intervention (Mechanism) Paying attention to the individual within workforce development can promote positive personal cognitive (e.g. personal efficacy) and instrumental impacts (e.g. skill development) and potentially impacts for the organisation (e.g. staff commitment) (Outcome).

Tapping into support workers’ motivations Deall cymhellion gweithwyr cefnogi If workforce development opportunities include elements of incentivisation (Context) then it is likely that participants will feel recognised and rewarded (Mechanism) The relationship between incentivisation and having a stake in workforce development can lead to greater emotional and practical participation and engagement with the intervention (Outcomes)

Joining things up around workforce development Cyd-gynllunio If interventions are developed in the context of an organisation’s goals including their human resource and quality improvement strategies (Context) this prompts alignment between the aims of the intervention and the goals of the organisation, such that they mutually reinforce each other (Mechanism). This leads to more sustained, lasting impact of the intervention, reducing turnover and supporting the organisations’ retention strategy (Outcome)

Co-design Cysylltu pethau yng nghyd-destun datblygu’r gweithlu If the right mix of people are engaged in the design of workforce development programmes/ interventions, (reflecting the complexity of workforce needs and desired development) (Context), this prompts co-design and a collective view about what needs to be done (Mechanism) which can lead to workforce development that is (perceived to be) more credible, meaningful, and relevant for the support worker with greater potential for positive outcomes for practice (Outcomes)

“Journeying together” “Cyd-deithio” If the right mix of people are engaged in delivering workforce development programmes/ interventions (Context) this can prompt learning together (Mechanism) which leads to stronger cohesion across groups, greater understanding of others’ roles and less duplication, and impacts on residents’ perceptions of care (Outcomes)

Taking a planned approach in workforce development Defnyddio dull bwriadus wrth ddatblygu’r gweithlu If workforce development draws on theory (both explicit and implicit), or there is evidence of a planned approach (Context) this prompts the adoption of a systematic process in its design and delivery (Mechanism) which leads to greater potential to demonstrate impact, and learn about workforce development effectiveness (Outcome)

Spreading the impacts of workforce development Lledaenu effeithiau’r gwaith o ddatblygu’r gweithlu …this prompts attention being paid to the way in which interventions at different levels reinforce one anothe r If workforce development interventions are comprehensive, in that they are multi-layered (focus on individuals, groups and organisations) and reflect broader developments relevant to the support workforce (Context) then this prompts attention on the way in which components of interventions reinforce one another (Mechanism) increasing the potential for impacts to embed and spread across organisations (Outcome)