Tables 1 and 2 detail key home and participant characteristics.
Thirteen themes within four core NPT constructs were generated.
Coherence: CONTACT Sense Making
Variable buy-in
Commitment to CONTACT varied between care homes and individuals. Home 3’s manager and champion demonstrated strong commitment: sharing study information with staff, encouraging participation and responding promptly to issues. The study champion regularly and enthusiastically contacting the research team. Home 4 manager’s commitment was less evident and whilst their champion was engaged, staff shortages limited involvement.
In Care Homes 1 and 2, managers were also study champions; and so directly committed. Home 1’s manager left abruptly, causing significant disruption, poor staff understanding and engagement:
“Staff and residents had a lack of understanding. My understanding wasn’t there, and I can’t expect someone to understand something that I don’t understand myself” (Home 1, study champion)
Legitimacy and credibility
The authority and credibility of those who introduced and endorsed CONTACT in the homes significantly impacted uptake and engagement.
“No investment from staff, it was not engrained within in the care home enough. As much as we could tell them to wear them, there are more than 100 people. I think it was up to the leads to encourage staff to wear the device, and that approach wasn’t there. The staff didn’t really remember or care to do it.” (Home 4, study champion)
Home 3’s study champion was well respected, and the manager reinforced CONTACT’s legitimacy by directly engaging with the study and communicating its importance to staff. In contrast, the absence of a strong advocate in Home 1 weakened the legitimacy of the project.
Engagement across roles
Engagement with the study varied across roles. Senior staff and managers demonstrated understanding and engagement - because they were involved with study tasks and communications. Non-managerial care staff, especially those working non-standard hours, or temporary staff (i.e. those employed by a care agency rather than the home) and who did not receive devices, had minimal knowledge of CONTACT.
Residents’ understanding and recall of CONTACT was extremely limited. Many accepted BLE wearables without hesitation. But most could not recall why they were wearing the device. For some, the device became “part of their routine”, while others were unaware of its existence. Despite being able to demonstrate understanding and capacity to consent to wearing devices during recruitment. Some residents misunderstood device purposes, believing they were fall alarms.
Care staff engagement
Care staff engagement with CONTACT was generally high, but not always:
“I wear my device at all times, but I know others take theirs off ...” (Home 2, care assistant)
Staff, while committed to the study, admitted to “forgetting” their devices and leaving them at home. The effects of this on routine data generated by the devices was unclear.
Care staff engagement was weakened by staff perceptions of data. Staff spoke of being perceived as, “not doing their jobs properly” (Champion, Home 4) because CONTACT revealed limited movement. Others thought BLE wearables could track them outside the home (they could not). We combatted this misinterpretation through messaging, the champions and managers. Concerns lessened as staff understanding of CONTACT’s purpose spread and improved.
Cognitive Participation: Work Promoting CONTACT Engagement
Identifying and Appointing Key Staff
Identifying study champions was an essential part of CONTACT’s implementation and evaluation plans. In one home, the manager selected two study champions to manage research coordination. Mindful of the researchers' warnings of potential pitfalls when managers assumed champion roles, the manager admitted a third study champion would have increased study feasibility as CONTACT meant deferring champions’ other work tasks. Conversely, the three smaller homes, managers/deputies opted to also be study champions; compelled by a perceived dearth of staff with the right skills and availability.
Champions, drawing on factors such as permanent status, leadership roles and established staff rapport, believed their roles were well positioned to advocate for and manage CONTACT. The unforeseen absence of Home 1’s manager-champion led them to express regret for not having appointed a deputy, and consequent disappointment in, “not meeting study team expectations” (manager and study champion, Home 1). The abrupt change in the home’s champion meant providing adequate training and comprehension of research activities suffered. To keep the home in the study the research team had to adapt and simplify research procedures. Past research used external researchers in the home - collecting data etc. - was reported as facilitating more participation.
Engaging The ‘Whole Home’ and Gatekeepers
Champions in conjunction with the research team used an array of strategies to foster engagement: a 'Change of Practice' notification, electronic mail introductions, social media group networks, as well as tangible (pens) and electronic promotional materials, and staff meetings. Engaging staff members who worked temporarily (i.e., agency or bank staff), weekends, or nights was challenging.
We procured ethical approval for verbally consenting staff. Home 3 employed an 'opt-out' approach, assuming participation unless stated otherwise. This strategy saved time but relied heavily on trust between managers and their teams. Study champions in other homes approached interested staff individually. All the champions and managers suggested increased researcher presence would have facilitated better engagement. They also acknowledged its impracticality: Home and University employer COVID-19 restrictions meant this level of presence was unfeasible.
Obtaining written consent from residents was assigned to care staff rather than researchers. For residents lacking capacity, champions enacted processes to contact nominated consultees. This was labour-intensive, required multiple phone calls and providing written information. Consultee unresponsiveness created further study delays.
To improve intervention understanding, the research team developed a staff guide on using, maintaining and cleaning CONTACT’s devices that we asked champions to disseminate. A succinct version came with each device to foster engagement and familiarity. Problems with study maintenance (battery changes) and care (reports of dirty devices, possible infection risk) were common in homes – especially Home 4, the largest and least engaged.
Enacting Study Tasks
Training helped champions with key tasks recruitment, screening, etc. But they often required additional support, walkthroughs, or reminders from the research team. These were delivered via phone, email, or real-time online demonstrations. Champions were proactive and confident in communicating uncertainties with the research team.
We needed staff to wear the device, ensure its visibility (to help accuracy and reinforce adoption), take it home (to avoid extraneous/false contact data), and assist residents with their devices. Home managers were confident most consented participants wore the devices. Although they acknowledged not all staff were totally committed. This variable commitment, even with a sound understanding of the study, led to inconsistency in performing study tasks such as weekly logs, notifying the research team of loss or breakage, and reporting positive COVID-19 cases.
Despite understanding participation requirements, non-champion participants often struggled to consistently adhere to study protocols due to competing work tasks and routines. The frequent turnover of staff and the employment of agency staff further reduced consistency.
Diverse Motivations
Staff motivations to participate in CONTACT ranged from mild interest in the study, managerial influence, indifference, to a desire to combat COVID-19, and enhance safety for residents.
Residents’ reasons for agreeing to participate in CONTACT included the desire to contribute to COVID-19 “efforts”, a belief in potential future benefits, or just wanting to participate with no clear rationale. Most were unable to recall their reasons for agreeing to participate. An extended timeframe, combined with difficulties in recall for some residents, between consent and start of the intervention exacerbated this: mean time from consent to issuing resident devices was 41 days (SD = 23.87).
Acceptability and 'Wearability'
Wearing the device in daily routines presented challenges for staff and residents. Staff often removed externally worn devices to prevent accidental contact with residents, contamination with food, or obstructing daily tasks (for example, providing personal care or food preparation).
Most staff wore devices consistently and adhered to protocols, but not always. Even when staff understood study requirements (coherence), they admitted to “forgetting” devices, wearing them in pockets and sometimes leaving them at work in lockers. Managing devices and daily study operations were resource-intensive tasks and not always undertaken successfully. In the largest home, power cables were lost and a wave scanner went missing for a week.
Many residents had removed devices, storing them in places such as drawers, tissue boxes, or handbags; reducing data accuracy.26 Staff sometimes attached devices to residents' belongings, such as walking frames and were confused about managing devices ‘found’ in the home. Some residents found the devices uncomfortable, frequently removing them. Residents with dementia particularly struggled with consistent device usage.
One manager (Home 3) noted residents did not consistently wear their devices and staff encouragement of residents decreased over time. Whilst staff demonstrated greater consistency in their device usage.
Observation in two homes revealed only a small fraction of staff and residents wore devices correctly. Despite managers' accounts of high device usage (~ 80% or more) and fidelity, many were not worn visibly on wrists or lanyards. One 15-minute observation session of 41 people (23 staff and 18 residents) showed only two staff and one resident wearing devices. Despite these inconsistencies, many staff indicated wearables were part of daily routines; only noticeable when they were obtrusive. Interestingly, we noted occasions where champions and managers were not wearing devices. One resident returned their device, tucked in an envelope labelled 'not mine’. Reasons given by staff for withdrawing residents from the study included residents not wanting to wear one or feeling distressed or confused by them.
Collective Action – CONTACT Enactment Work by Individuals
Workload Vs. Available Resources
All homes described CONTACT’s workload as substantial, demanding and adding to usual duties. Particularly burdensome were participant screening log completions, obtaining consent, and registering participants. These tasks were complicated by paper-based staff and resident data storage and rudimentary digital infrastructure. Whilst most screening was completed within the required period the largest home needed more time: more participants meant more work. Some study champions extended working hours to complete study-related tasks.
Securing resident consent or assent from consultees was time-consuming. Homes devised strategies, such as intercepting next of kin on planned visits. Such work arounds were not scalable to larger homes.
After initial screening, consent, registration and device distribution, staff focus shifted toward device management and data collection. This involved regular tasks like submitting weekly reports on new participants, withdrawals, deaths, device management, and battery replacements. They also had to keep a daily log of COVID-19 cases, report cases, and attend a weekly call with the research team to review reports, monitor progress and address issues. Despite study tasks described as “burdensome” and “time-consuming”, homes mostly completed tasks on time. Weekly support calls from the research team were highlighted by champions and managers as “essential”. As time progressed and knowledge increased some homes were able to submit weekly data independently.
Staff had to allocate time in their work week for CONTACT’s additional responsibilities. This meant rearranging or deferring usual work. All managers and champions found the workload unsustainable in the long term without dedicated staff or additional support; especially if they were to incorporate CONTACT technology into current care delivery in a similar pandemic context. Having committed to the study, most felt capable of “handling the work”; but just for the intervention period.
Despite explaining study tasks to consenting homes, the full extent of the study involvement was only clear after starting:
“…difficult to prepare for such a big workload when one doesn’t know what’s coming. Don’t know until you do it. Wouldn’t have put us off, but we would have been better prepared” (Home 4, manager)
The pandemic context shifted. We recruited homes pre-vaccination, but delivered CONTACT post-vaccination. One manager detailed how they “made room” for CONTACT due to the urgency of the research:
“Because of the nature of why I took it on and being in the middle of COVID, I didn’t have the capacity. But the importance to me of doing it made me make the capacity. I still would argue I don’t have the capacity, I know I’m speaking to you today, so I’ve made sure all my forms are done, so I do need to have this weekly checkpoint, otherwise I would easily drift. It’s the most involved study I’ve done where I’m involved doing it and collating and understanding it. But the importance of the study outweighs what I would do” (Home 2, manager)
Fob battery replacement was an unforeseen and laborious task. Collecting devices, changing batteries, returning the devices, and logging changes was time consuming for staff. Staff in Home 3 managed to change batteries themselves but delays in Home 4 meant a researcher going in to change 34 batteries for the staff over two days.
Field notes from the largest home confirmed the complexities of managing recruitment. Balancing different tasks and apprehension about the daunting task of resident recruitment resulted in a delayed last-minute start to recruitment. Despite advice from researchers that this task should be undertaken first due to its time-consuming nature, the champion did not respond to emails and calls and a (self-declared) “sense of panic” ensued. Reassurance and emphasising the importance of effective communication and asking for help meant delays in resident recruitment were minimised.
Study procedures were made more complicated by research governance requirements – adding to staff perceptions of complexity. Each device had a unique number that was cross-referenced against each home’s 'master log' to identify the wearer from anonymised reports. Communication involving identifiable data had to be conducted via a secure file transfer system. The secure databases used for registering participants and reporting COVID-19 cases experienced technical difficulties – introducing more delays and effectively “negative feedback” for homes that had spent time reporting cases and expected a rapid response.
Training And Support for Homes at a Distance
COVID-19 restrictions prevented almost all in-person visits or training in the homes. An introductory session and three shorter online ‘micro training’ sessions covering study activities were offered. Whilst all participants found the training comprehensive, some found it too intense. Table 3 reveals the adequate but variable uptake of training of key staff.
Table 3
Home | Invited | attended | % |
#1 | 9 | 3 | 33.33% |
#2 | 4 | 4 | 100.00% |
#3 | 7 | 5 | 71.43% |
#4 | 14 | 10 | 71.43% |
Total | 34 | 22 | 64.71% |
[Table 3 here]
Credibility of CONTACT Data
Confidence in the CONTACT triggered and scheduled reports (see Appendices A and B) varied because of scepticism regarding the accuracy of contact location and devices (individuals) involved. Staff recalled instances where contacts occurred in “unusual” places or between people who would “not usually interact”. Doubts that led some staff to believe devices could record contacts through walls and ceilings, generating further scepticism:
“I wasn’t confident with some of the data on the scheduled report because the locations were showing people were having contacts and congregating in the corridors, and I know for sure that they don’t meet there. So that was lacking in the accuracy, a lot of the contacts in my home happen in rooms, like day rooms and dining rooms” (Home 3, manager)
One home’s lack of confidence in CONTACT data hindered report sharing and led to them questioning their study participation:
“The data collected didn’t reflect what was happening in the home. The devices seemed too sensitive. I was therefore dubious of the data. I lost a bit of faith and questioned what I was doing. One of the reports showed two residents who have never had contact did have contact, but their rooms are directly above each other” (Home 4, manager)
Conversely, when reports confirmed expected contact patterns, confidence in reports improved:
“The scheduled reports seem to replicate what was happening, it made sense as it showed staff were supposed to be where they should be. That give me the confidence it was picking up the people it should. It then translated into confidence that it would be a useful tool to monitor where the infections were and how they would be transferred” (Home 1, manager)
“The triggered report was helpful as it confirmed what we suspected. One resident for example said that was positive, her neighbour goes into her room a lot and we see this in the report and a staff member that seen her on the day. We tested both individuals, and both were (COVID-19) positive” (Home 4, manager)
Despite study reports providing insights into contact patterns, they did not impact on IPC protocols or behaviours. Staff felt current practices, aligned with national guidelines, were effective – even if current IPC guidelines were, in truth, of uncertain benefit.
Reflexive Monitoring – Appraising CONTACT
CONTACT reports were largely confined to home managers/champions. Consequently, staff were unfamiliar with the information and its potential benefits, leading to lower engagement and less opportunity for learning. The largest home was wary about acting on reports because highlighting staff behaviours was problematic:
“We can’t do much with the triggered reports… We can see that a person is in the smoking area for so long, but we can’t approach them to say anything because that would decrease their trust and they wouldn’t wear the devices. That would then spread to other people as they think they’re being tracked” (Home 4, study champion)
Staff saw daily testing as adequate protection from infection without threatening staffing levels or relationships. Whereas CONTACT’s information was harder to operationalise and risked making scarce (human) resources scarcer.
“The triggered report covered mostly what we knew already. I did analyse the scheduled report which identified which residents are most at risk. But if you find out which individuals are most at risk, what can you really do with that information? We can make people isolate but then you lose staff. The staff do a lateral flow test before work every morning, that’s the protection we already have, without losing too many staff” (Home 4, study champion)
Home 3’s manager welcomed the study's triggered report when understanding the infection source of two COVID-19 positive staff. Since no other cases were identified, the infections were likely acquired outside the home. In Home 4, the report supported the view that an isolated resident’s lateral flow test result was a false positive – later confirmed by polymerase chain reaction (PCR) tests. Managers recognised the potential utility of the data in establishing isolation zones, escalating testing, and preventing home-wide shutdowns. Crucially though, outside a research context:
“…I can see in the future how it could work, preventing us having to close because we’ve got two cases out of 80, we can easily isolate pockets of people if we needed to and staff as well. So, I can see if we didn’t have the national guidelines in place, where it would give me research-based information to make risk assessment decisions. If this wasn’t a trial and we had this info because this was the system we were using, I would feel comfortable saying, “hang on a minute, this is showing, this is showing and this is what we can do about it” as an assessment to present to anybody. In the guidelines, it does say that registered managers are accountable for decisions, but outside of a trial, it would have given me the confidence to say this is what the infection is doing and we can safely isolate that and carry on doing what we are doing with the other residents, so the residents don’t suffer from lack of visitors” (Home 3, manager)
Intervention aspects, such as location markers and wave routers, became routine. But wearing devices consistently did not. Maintaining the intervention independently would be challenging without additional support: individuals or teams with sufficient time:
“I think if it is part of infection prevention strategy then you have got someone running it then it would become part of that strategy and part of the way we work. I think if it was a dedicated person’s role, and they had a team of assistants [in the home’s communities] then it would work… I think if we were to carry on from the point that we are at now, it would be more recognised and more part of the day-to-day stuff. That’s how people have started to think about it now. If we went on for another year at the level we are at now, it would have been common practise for residents and staff. More time to become normalised, that’s the right word” (Home 4, manager)
Table 4 details the NOMAD scores from home managers. Except for Home 2 at commencement, and noting Home 1’s lack of end data, homes were broadly positive in their assessment of familiarity and possibility of normalisation. The differing NoMaD (sub) dimensions suggests a lack of consensus between homes. A notable exception is the positive evaluation of the chances of feedback improving future versions of the CONTACT intervention.
Table 4
home manager's NOMAD assessments
NoMaD item | | Care home (CH) and time point (Start/End) |
CH1 (Start)$ | CH1 (End) | CH2 (Start) | CH2 (End) | CH3 (Start) | CH3 (End) | CH4 (Start) | CH4 (End) |
When you use devices, how familiar does it feel* | 10 | - | 8 | 5 | 6 | 10 | 8 | 10 |
CONTACT is currently a normal part of your work* | 5 | - | 5 | 5 | 6 | 7 | 8 | 10 |
CONTACT will become a normal part of your work* | 10 | - | 2 | - | 9 | 7 | 10 | 10 |
Differs from usual ways of working‡ | 7 | - | 3 | 2 | 2 | 2 | 3 | 2 |
Staff have a shared understanding‡ | 2 | - | 2 | 2 | 2 | 3 | 3 | 3 |
I understand how CONTACT affects the nature of my work‡ | 3 | - | 2 | 3 | 2 | 2 | 2 | 2 |
I can see the potential value‡ | 1 | - | 2 | 3 | 1 | 1 | 1 | 1 |
There are key people who drive CONTACT forward and get others involved‡ | 1 | - | 3 | 2 | 2 | 2 | 1 | 1 |
I believe that participating in CONTACT is a legitimate part of my role‡ | 4 | - | 2 | 2 | 2 | 2 | 1 | 1 |
I am open to working with colleagues in new ways to use CONTACT‡ | 1 | - | 2 | 2 | 2 | 2 | 1 | 1 |
I will continue to support CONTACT‡ | 1 | - | 7 | 3 | 2 | 2 | 1 | 1 |
I can easily integrate CONTACT into my existing work‡ | 1 | - | 2 | 4 | 2 | 4 | 1 | 1 |
CONTACT disrupts working relationships‡ | 4 | - | 4 | 3 | 4 | 4 | 5 | 5 |
I have confidence in other people's ability to use CONTACT‡ | 1 | - | 2 | 4 | 2 | 4 | 4 | 3 |
Work is assigned to those with skills appropriate to CONTACT‡ | 4 | - | 3 | 3 | 2 | 2 | 1 | 1 |
Sufficient training is provided to enable staff to implement CONTACT‡ | 2 | - | 1 | 2 | 2 | 2 | 2 | 1 |
Sufficient resources are available to support CONTACT‡ | 2 | - | 1 | 2 | 3 | 4 | 2 | 1 |
Management adequately support CONTACT‡ | 1 | - | 1 | 3 | 2 | 2 | 2 | 1 |
I am aware of reports about the effects of CONTACT‡ | 2 | - | 1 | 3 | 7 | 2 | 2 | 1 |
The staff agree CONTACT is worthwhile‡ | 2 | - | 3 | 4 | 7 | 3 | 2 | 2 |
I value the effects of CONTACT has had on my work‡ | 2 | - | 3 | 4 | 7 | 2 | 2 | 2 |
Feedback about CONTACT can be used to improve it in the future‡ | 2 | - | 2 | 2 | 2 | 2 | 1 | 1 |
I can easily modify how I work with CONTACT‡ | 2 | - | 3 | 3 | 3 | 3 | 1 | 1 |
$CH1 did not provide end data |
*Rated from 0 (unfamiliar) to 10 (completely familiar); ‡ 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, 5 = strongly disagree, 6 = not relevant for my role, 7 = not relevant at this stage |
[Table 4 here]