Social care - defining, evidencing and improving: mixed-methods qualitative study

5. Methods

This research project was informed by the academic discipline of 'knowledge mobilisation', which involves studying how knowledge moves between people and organisations (Ward 2017). It starts from an understanding that each person involved in the policy process will have different conceptualisations of what counts as 'good' and what counts as legitimate evidence for it. This aim of the research was therefore to listen to these different perspectives and understand how they can be brought together meaningfully to shape how policy makers define, evidence and improve social care in Scotland. The project used a qualitative research design, which is best suited to accessing people's opinions, experiences, and ideas in depth. Objective 1 involved asking people to look back on their experiences of contributing evidence to a specific piece of policy work, whereas objective 2 involved asking people for their general opinions on evidencing and improving social care with a focus on the future. Combining this focus on both specific and general experiences and opinions, whilst looking simultaneously to the past and to the future, meant that the research could explore participants' perspectives on what actually happens as well as what they would like to happen when it comes to evidence-informed policy making in social care. The methods for each objective are detailed below.

5.1 Objective 1: Interviews with stakeholders involved in the development of the 'The Healthcare Framework for Adults Living in Care Homes'

Interviews were conducted with 20 people involved in the development of the 'Healthcare Framework for Adults Living in Care Homes' Background information on the Healthcare Framework is provided in Box 1.

Box 1. Background information on the Healthcare Framework

The 'Healthcare Framework for Adults Living in Care Homes' was published in June 2022 following an extensive development period with a reference group including a six-month period of stakeholder engagement. To provide people living in care homes with the same access to, and continuity of, healthcare as people living in their own homes it outlined recommendations in relation to 6 core elements:

1. nurturing environment

2. the multi-disciplinary team

3. prevention

4. anticipatory care, supporting self-management and early intervention

5. urgent and emergency care

6. palliative and end of life care

These elements are all underpinned by a set of recommendations in relation to a skilled workforce and effective use of data/digital/technology. The framework is intended to provide information, assurance and direction to all those involved in and affected by the provision of healthcare in care homes i.e. people living in care homes and their families, people working in care homes, health professionals caring for people in care homes, and care home providers.

The framework states that it is based upon a definition of health that extends beyond the physical, to include social, psychological and spiritual health in the context of social relationships and community connections. As such, the framework highlights the role that the health and social care workforces, both together and separately, play in contributing to the broad health and wellbeing of adults living in care homes.

5.1.1 Rationale for focussing on the Healthcare Framework

Making visible how initiatives like the Healthcare Framework are shaped by evidence and decision making can help to advance our understanding of policy design (Haelg et al 2020). Howlett (2014) defines policy design as "the deliberate or conscious attempt to define policy goals and connect them to instruments or tools that will realise these goals" (p.58). Referring to this definition, the Healthcare Framework is an example of a 'tool' for achieving the goals of the National Care Service. It is described in the Ministerial foreword as "a pivotal building block in improving outcomes as we move towards the establishment of the NCS" [5]. Its development was led by a team of policy makers, in collaboration with a large reference group consisting of stakeholders from care homes, academia, health and social care partnerships, third sector, and scrutiny and improvement bodies. The policy team also engaged in a consultation process involving stakeholder engagement events, an online survey, focus groups and good practice returns. The framework states that "the various comments, stories, experiences, opinions and suggestions from these engagement activities [were used to] to shape the framework and inform the recommendations". As the aim of this research project was to explore and understand this process from a knowledge mobilisation perspective, The Healthcare Frameworkprovided a particularly good case study for two reasons:

1. Who developed it:

The framework brought together people and knowledge from different backgrounds to develop a single set of recommendations. Definitions of 'good' are subjective and conditional; how different actors perceive and use evidence in policy decisions will vary according to their own beliefs, values, experiences and opinions. Studying the Healthcare Framework therefore provided an opportunity to understand how those involved in its development – and their relationships – negotiated what evidence was sought, listened to and incorporated within the framework. It also permitted exploration of the assumptions underpinning what is considered evidence of 'good' social care from these differing perspectives.

2. When it was developed:

The publication of the framework early in the study timeframe meant that interview participants would be able to recall the decisions they made and how, whilst being far enough in the past that there was time for reflection and learning to take place. With the Healthcare Frameworkin the early stages of implementation, the research could explore decision making both retrospectively and prospectively. This was useful for understanding how evidence of, and assumptions about, 'good' social care were actively incorporated into policy and to inform the future roll out and evaluation of the framework.

5.1.2 Interview structure and participants

Interviews (n=20) were semi-structured and invited participants to: describe their role in the development of the Healthcare Framework; share their understanding of how different types of evidence informed its development; give their perspectives on what 'good' social care looks like and how it is evidenced; and share their opinions and ideas on how the Healthcare Frameworkcould be implemented and evaluated as part of improving social care. The topic guide was followed flexibly, allowing participants to lead the conversation and using prompts only when necessary. In keeping with the Civil Service Management Code, policymaker interviewees were asked only to provide information on the policy process and the means used to incorporate evidence, rather than sharing their personal opinions.

Interviews lasted on average 63 minutes, with the shortest interview being 27 minutes and the longest being 1 hour 26 minutes. Interviews were digitally recorded and transcribed for analysis purposes. All interviewees opted to take part in their interview virtually, except for one person who chose a face-to-face interview. Interviews were all one-to-one, except one interview where two participants opted to be interviewed together.

Interview participants included: 5 Scottish Government policy makers; 3 Scottish Government Professional Advisors; 3 representatives from healthcare; 5 social care representatives; and 4 care home owners/managers. Interviewees are identified throughout this report by a unique number, as outlined in Table 1. No further details are provided to maintain anonymity.

5.2 Objective 2: cross-sector, creative research workshops

A combined total of 64 participants attended two half-day, in-person research workshops. Both workshops used creative visual research methods, a methodological approach to qualitative research that has been shown to facilitate rapport, encourage openness, enable discussion of sensitive topics, encourage discussion that is tangible and future-focussed, and reduce power imbalances between participants. Workshop 1 asked participants to answer the question: "what does good social care look like and how can we evidence it?". Workshop 2 asked participants to co-create a vision for a future national approach to social care improvement under the NCS.

5.2.1 Workshop Participants

Thirty-five participants attended workshop 1, comprising people with lived and living experience of social care (n=5), people working in social care (n=22), academic researchers (n=3) and representatives from Scottish Government (n=5). Of the participants who worked in social care, they represented organisations in the third sector (n=14), private sector (n=5) and local authorities (n=3). Participants working in social care were predominantly from adult services, with 3 participants representing children's services. Geographically, participants were predominantly from the central belt, with the exception of 5 people from other areas in Scotland.

Twenty-nine participants attended workshop 2, comprising people working in adult social care (n=6) , people working in healthcare (n=5), representatives from professional, regulatory and improvement bodies (n=11), academic researchers (n=5) and representatives from Scottish Government (n=1). Geographically, 15 participants were from the central belt, with 14 people from areas across Scotland.

5.2.2 Workshop Methods

Workshop 1: "What does good social care look like and how do we evidence it?"

The aim of this workshop was to bring together people with different perspectives on social care in Scotland. It was held in Edinburgh on 23^rd February 2023 and involved two linked creative methods to support conversation and elicit qualitative data:

• Object-based discussion of what 'good' social care looks like (summarised on large sheets of paper, which were displayed for the whole room to see and used by the researcher for analysis);
• Collage-making activity on evidencing good care in an inclusive way. The collages and a transcript of the feedback from all groups were analysed as data by the researcher.

Additional information on these approaches can be found at Annex B.

Workshop 2: "Visioning a distinctly social care approach to improvement"

The workshop was held in Dundee on 28^th March 2023 and involved using future visioning techniques. Participants were provided with creative materials and worked in small groups to create a visual representation of the social care improvement approach operating in 2080. They were challenged to vision what is possible, suspend doubts and identify the characteristics of an ideal approach based on what they perceived to be distinctly social care values, knowledge and skills. Participants were then asked to look back from their new vantage point in 2080 to identify: elephants in the room, barriers and blind spots (defined in Box 2). Finally, participants were asked to write a letter back in time, combining their lessons from the future into actionable advice for policy makers, researchers and practitioners in 2023 to identify what can be done, and how, to realise their vision for a future social care improvement approach. Groups provided feedback to the whole room after every activity. The visual work produced and a transcript of the feedback from all groups were analysed as data by the researcher.

Box 2. Prompt questions for the elephants, barriers and blind spots exercise

The social care approach to improvement in 2080 – how did we build it?

Now that you have designed and described the social care approach to improvement operating in 2080, it is time to look back how we built it. From your vantage point in 2080, reflect on how it was developed. What were the:

Elephants in the room?

What were the questions we were too afraid to ask?

What were the consequences of facing these (or not)?

Whose voice finally got these questions across and how?

Barriers?

What were the barriers in the way of progress?

How were they identified and overcome?

Who had the knowledge and resources we needed?

Blind spots?

What were the stumbling blocks that we didn't predict?

Why did they arise and how did we miss them?

What were the consequences of these blind spots?

5.3 Data analysis

Audio recordings of interviews were transcribed by an external company. Transcripts from workshop feedback sessions were provided by a professional videographer who filmed the workshops. Workshop data and interview data were analysed concurrently to permit comparison between data sources. Data were analysed using a modified framework method with reference to Gale et al (2013). Data were coded by the researcher using a combination of paper hard copies and the software package Nvivo 12. Both workshop and interview data were first coded inductively – with no preconceptions or predetermined framework – to generate initial themes. A

second round of analysis involved coding the data deductively into three categories corresponding to objectives 1 and 2, specifically: "defining good care"; "evidencing good care"; and "improving good care". The researcher then compared and contrasted the findings from both rounds of analysis, with a specific focus on integrating the findings into a conceptually coherent and practically useful model.

5.4 Limitations

The findings presented in this report are shaped by the specific composition of participants who took take part in the study. A different combination of participants may have yielded different concepts. Owing to the creative and interactional nature of the workshops, it was not possible to differentiate between specific participant voices or to separate individual views from collective group feedback. The "3Rs" model presented in this report, however, is not offered as undisputed fact, but as one possible definition of 'good' social care. It is not intended to be prescriptive or definitive and can be applied and adapted flexibly to help support discussions around social care design, delivery, evidence and improvement.