Participants and setting

The qualitative study was carried out in five care homes that participated in testing the validity and reliability of ORACLE. All participating care homes had a good rating by the CQC. Two categories of care staff were eligible to participate in the semi-structured interviews. The inclusion criteria were:

1. 1). Managers, registered nurses, or senior staff members engaged in coordinating the application of ORACLE in the care homes.
2. 2). Healthcare assistants routinely engaged in the care of residents and who conducted ORACLE assessments.

Previous research suggests that data saturation typically occurs after 6–12 interviews [22]. A purposive sample of 10 care staff members was determined, based on available resources and pragmatic considerations. Participants were purposively selected based on the eligibility criteria. The sampling process was informed by the principle of data saturation, with interviews conducted until no new themes were identified. Saturation was evaluated iteratively throughout the data analysis, and by the tenth interview, it was clear that no key themes had been repeated.

The participants included care staff working across a variety of care homes, including nursing, residential, mixed or specialised care facilities (dementia, neurological, etc.). For confidentiality purposes, participating care homes are not named. The care staff primarily cared for elderly residents with minimal support needs or those who required regular assistance with activities of daily living, individuals with cognitive impairments, learning disabilities and chronic health conditions.

Semi-Structured interviews

The semi-structured interviews were conducted between 15^th February and 30^th May 2024 either remotely over secure videoconferencing or face-to-face in a private room at the care homes, depending on the convenience of the participants. The interviews lasted between 40 and 60 minutes, were audio and video recorded and transcribed verbatim by HT.

The semi-structured interview guide (S1 Appendix) was developed based on the research aims through discussion among the research team members and using results from a Delphi survey [19]. Participants were asked socio-demographic questions, including their age, gender, and years of experience in care facilities, as well as questions about the usability of ORACLE. Carers were asked about their experience of completing the ORACLE assessments, e.g., how easy or difficult it was to incorporate the tool into their work routine. Additionally, senior staff members, including managers, were asked about their experiences to gain a deeper understanding of the context of the care homes for practical implementation of ORACLE, including whether the care home had the appropriate time, staff and skills resources to perform assessments regularly. Follow-up questions were asked based on the participants’ responses and experiences. Field notes were taken during and immediately after each interview to capture contextual observations.

Ethics

This research study has been granted a favourable opinion by an independent NHS research ethics committee, Camberwell St Giles REC (IRAS Project ID: 318311) and the Research Ethics Committee at Bournemouth University (Ethics identification number: 45572). All participants provided verbal and signed informed consent at the beginning of each semi-structured interview and could opt to withdraw at any time. The data was only accessible by the research team, and all transcripts were pseudo-anonymised prior to analysis.

Data analysis

HT checked the audio files and corresponding transcripts to correct auto-transcription errors and ensure anonymisation. The transcripts were then imported into qualitative data management and analysis software (NVivo). The transcripts were analysed using reflexive thematic analysis following Braun and Clarke’s approach [23]. A coding framework was developed iteratively during analysis by KC and HT.

This was followed by a 5-step process of familiarisation, identifying a thematic framework, indexing, charting, mapping and interpretation [23]. Field notes were used to support contextualisation and interpretation of the transcripts. Coding was conducted using a hybrid approach of deductive and inductive reasoning [24]. The deductive coding was informed by a set of a priori codes derived from the interview guide, while the inductive coding allowed for the generation of new codes and subsequent development of themes. Once coding was complete, overarching themes were developed, and the prominent quotes were identified for extraction based on those themes. Open discussions and iterative revisions were carried out among the research team to reflect on the quotes, thematic coding, and interpretation. Disagreements were resolved through discussion and consensus (HT, KC, JD, and SP).

Researcher reflexivity

The first author, a PhD student with a physiotherapy background, conducted this study as part of their doctoral research and was closely involved in each phase of the study, from design to data collection and analysis. All participant interviews were conducted by the first author, who had prior experience and training in qualitative research methods. The broader research team, which included a physiotherapy academic, a nursing academic and a clinical physiotherapist, played an active role throughout the research from conception through to write-up. Their multidisciplinary input, coupled with regular critical discussions, helped to minimise the individual bias and enhanced the trustworthiness and methodological rigour of the study.

Patient and public involvement and engagement (PPIE)

A face-to-face PPI session was conducted with five healthcare assistants (HCAs) from a local care home prior to the formal testing of ORACLE in care homes. They provided written and verbal feedback on the ORACLE tool, which informed the development of a short training package [25] and minor revisions in ORACLE. Their input ensured that the tool was easy to comprehend and that the terminology used was accessible for staff who lacked formal medical training.

Overarching themes

From the data analysis, three overarching themes were identified: 1) usability of ORACLE, 2) acceptability of ORACLE and 3) contextual factors that can potentially influence the practical implementation of ORACLE in a care home setting (Fig 1). Most of the themes and sub-themes were primarily deductive, and closely aligned with the interview guide. However, several sub-themes were developed inductively through analysis of the data. Specifically, within theme 2: acceptability, inductively derived sub-themes included quality of care and behavioural changes in practice. Within theme 3: contextual factors, inductive elements included dementia, motivation and engagement, and consistency of care.

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Fig 1. Thematic map.

Fig 1 illustrates the three overarching themes and sub-themes extracted from the analysis.

https://doi.org/10.1371/journal.pone.0335658.g001

Usability

Usability is a key consideration in care home settings with demanding work schedules. For successful implementation, the outcome measures must be quick to use, accessible, and easy to integrate into existing workflows [27]. Outcome measures that are time-consuming or have complex scoring systems are difficult to implement in practice and increase the chance of errors in risk assessment [27,28]. The aimed users of this tool are care staff, particularly the healthcare assistants (HCAs). Given the care home context, where formal medical assessments may not be feasible or practical for the care staff, ORACLE was developed with an emphasis on observable and physically examinable factors, which HCAs can easily and quickly assess during their usual care routines. In support of this, several studies have shown that assessment scales that are easily comprehended across different contexts and populations have broader applicability in implementation science [29].

Some challenges were identified in categorising residents into ranks using ORACLE by a few staff members. This difficulty could be attributed to the significant gap between the training provided to carers and the actual data collection, leading to potential lapses in recalling how to effectively rank the categories. Research shows that time away from training may impair skills and competence, potentially affecting the practical application of the intervention [30].

Acceptability

Acceptability has been identified as a critical factor in the success or failure of implementing a new intervention or new practices in real-world settings, as reported by Proctor et al (2011) in their study [31].

In the current study, staff expressed confidence that ORACLE has the potential to improve the quality of care of the residents. A previous quality improvement study conducted in several care homes demonstrated that empowering care staff with education on pressure risk assessment significantly reduced the incidence of Stage I pressure ulcers [32].

Additionally, care staff reported improved awareness about the residents’ mobility and contracture risk following the training sessions and the practical use of ORACLE in practice.

These findings are also consistent with those from a previous study by Petyaeva et al [2018] on the feasibility of a pain assessment intervention for care home residents with dementia. The study showed that the intervention improved staff awareness, increased staff confidence and informed decision-making across the staff [33]. Another study by Damery et al [2021] also found that upskilling care home staff can improve working practices that may be associated with reduced avoidable harms like falls, pressure ulcers, and urinary tract infections [34].

Contextual factors

Care homes are complex environments where the implementation of an intervention or a service depends on its properties and how it interacts with the environment in which it is introduced [35]. Identification of these factors, e.g., organisational practices, provides insight into the barriers and facilitators to effective implementation and provides implementation strategies care homes can adopt to enhance the sustainability of the service introduced [26,36,37]. Three types of contextual factors were identified in this study: resident-specific, social, and organisational.

Resident-specific factors

Care staff found it challenging to implement preventative guidance for residents with communication challenges, particularly those with severe cognitive impairments. They suggested additional guidance in ORACLE for dementia residents. Previous research has shown that using supplementary materials, such as flashcards, can improve care practices for dementia residents [33].

Care staff also highlighted the importance of nutrition and hydration in ensuring residents have the energy needed to move around. Conversely, overweight residents might also struggle with mobility. Evidence supports that both undernutrition and obesity are associated with low mobility levels among care home residents [38].

Additionally, care staff believed that certain medications and polypharmacy significantly impact residents’ mobility. This is reinforced by evidence that polypharmacy is associated with mobility problems in care home residents [39]. Furthermore, adverse drug reactions, such as cognitive impairment and falls, are among the leading causes of hospital admissions in older adults [40].

Social context

Care staff emphasised that support from family and peers plays a key role in keeping the residents socially engaged and motivating them to do physical activity, an important preventative measure for contractures. This is supported by literature, which shows a strong association between psychological and emotional well-being and physical health and disability levels in care home residents [41]. Family and peers play a key role in enhancing the residents’ quality of life through visiting, offering emotional support, monitoring well-being, maintaining social connections, and promoting a positive adaptation to care home life. These factors contribute to the overall social engagement and motivation of care home residents [41,42]

Organisational context

Care staff expressed that the guidance provided by specialists to HCAs could be more detailed and improved. Research has consistently demonstrated that high-quality external support services, like physiotherapy delivered through targeted exercise plans, can significantly benefit care home residents [43]. These services can help enhance muscle strength, improve joint flexibility, reduce pain, and promote both physical activity levels and functional independence [43,44]. Staffing levels and high workload were also identified as important organisational contextual factors in contracture prevention and effective implementation of ORACLE. Evidence suggests that staff workloads and turnover rates are high in the care home sector, which may influence the long-term sustainability of a new intervention [45]. Previous studies have reported that care staff often lack the time to integrate physical activity into daily routines due to heavy workloads [46,47]. Consequently, inadequate staff-to-resident ratios may limit the time available to implement ORACLE and related preventative measures effectively.

Study limitations

This study had a few limitations. First, we were unable to recruit any nursing staff from the participating care homes, potentially leading to an incomplete representation of the diverse experiences of all care staff. Second, there was a time delay between the training and the actual data collection in some care homes, which could have influenced participants’ recall and application of the training content. Moreover, although purposive sampling was used, the views of the participants may not be representative of all care staff. All these limitations should be considered when interpreting the findings of the study.

Care homes

Care homes that emphasise holistic care approaches, including proper nutrition and hydration, may find ORACLE more effective, as the tool’s assessments are integrated into broader care strategies. Additionally, medications and polypharmacy were identified as important factors affecting the mobility levels of the care home residents. Care home staff must understand these effects and coordinate with the General Practitioner (GP) to integrate medications into the residents’ routines to minimise their effect on overall mobility and improve ORACLE’s efficacy.

People

Both care assistants and residents are crucial in the practical implementation of ORACLE. Care assistants must navigate the complexities of each resident’s motivation and engagement levels when using ORACLE. For example, a resident’s willingness to participate in activities or mood can significantly affect their assessment outcomes, particularly in areas related to functional ability and mobility. This also highlights the importance of understanding the residents’ psychological and emotional states, often influenced by their interactions with care staff, family, and peers.

Family and friends’ support is another critical factor that can influence the practical implementation of ORACLE. Residents with strong family ties may show different levels of engagement and motivation, affecting their risk of developing conditions like contractures. Family visits can either motivate residents to be more active or, conversely, lead to emotional distress that impacts their physical engagement. ORACLE’s assessments must consider these dynamics, requiring care staff to make decisions that reflect the resident’s physical condition and social and emotional context.

Training and support

Given the challenges identified, particularly with language and categorisation, there is a clear need for enhanced training and support for care staff using the ORACLE tool. Providing additional guidance, such as specific guidance for Dementia residents, could help mitigate confusion and ensure consistent tool use. Organisational support is also essential, such as allocating adequate time for staff to learn and use ORACLE effectively. The findings from this study will be utilised to further refine the ORACLE and develop an implementation guide for care homes.

Policy

Currently, the Care Quality Commission (CQC) does not explicitly mandate the prevention and management of contractures as part of its regulatory framework for care homes in England [48]. This contrasts with the Omnibus Reconciliation Act (OBRA) of 1987, which governs long-term care facilities in the United States, and explicitly states that care homes must ensure that measures are taken to prevent contractures [18]. Similarly, in Germany, joint contracture risk assessment and prevention have recently been defined as a quality indicator for nursing homes, regulated and monitored by experts from the statutory health insurance system [11]. According to this regulation, nursing homes in Germany must report whether they regularly carry out risk assessments for joint contractures and implement relevant preventative measures [11]. This highlights a critical gap in the policy that could impact the implementation of ORACLE as a standard risk assessment tool across care home settings in England. While ORACLE offers a practical solution for addressing this issue, its application in practice would be limited by the absence of a formal requirement for care homes to monitor and prevent contractures. This policy change would also ensure that care homes are held accountable for implementing effective strategies to prevent and manage contractures, thereby promoting consistency of care and improving the overall quality of care. Additionally, incorporating contracture prevention into CQC requirements would necessitate training and resource allocation changes within care homes. Staff would need to be trained in using tools like ORACLE and understanding the broader factors that contribute to or impact contracture development and prevention, such as dementia, nutrition, hydration, medication management, and psycho-social support.

Practice implications

For care homes, key considerations should be given to organisational practices, staffing, regular training, and appropriate and timely specialist support to implement ORACLE effectively. Additionally, policy frameworks and standards must be in place to ensure accountability for care homes and the long-term sustainability of ORACLE.