Exploring Care Home Workers' Perceptions of Implementing ECHO: A Qualitative Study

ABSTRACT

Background

To ensure older people living in care homes receive optimal care, care home workers (CHWs) require access to specialist support and education. Extension for Community Healthcare Outcomes (ECHO) uses existing videoconferencing to connect CHWs to specialists using case‐based learning. There is evidence in other settings to suggest that ECHO can improve practitioner knowledge and patient outcomes. There is a dearth of evidence regarding strategies for effective implementation of ECHO with CHWs.

Aim

To establish the experiences of ECHO, and the barriers and enablers to implementation, from the perspective of CHWs in Scotland.

Methods

Qualitative online focus groups (n = 4) with CHWs (n = 13) who had participated in at least one care home ECHO session and with facilitators/presenters (n = 6). Transcripts were thematically analysed.

Findings

Findings were grouped into three areas: perceived impact, inhibitors and enablers. CHWs reported the positive impact of ECHO including key benefits to enhance residents' care, satisfaction with the sessions and feeling valued. Inhibitors included limited digital skills, workforce challenges and the pitch and duration of ECHO sessions. Enablers included administrative and technical support, scheduling and the structure of the ECHO approach.

Conclusions

ECHO allows CHWs to access specialist support, enabling learning and development, with the potential to improve residents' care. Benefits to residents' care included CHWs' enhanced understanding of choices around death and dying, and insights and understanding of causation of challenging behaviours in older people and how to manage these. Adaptations to ECHO to suit a care home context are recommended.

Implications for Practice

CHWs require technical support to build competence and confidence in IT skills. This study highlights the potential for ECHO to support CHWs to access specialist support and learning for older adults in a care home context.

Summary.

• What does this research add to existing knowledge in gerontology?

  • ○
    CHWs require access to specialist support and educational opportunities to support care of the older adult in care homes/long‐term facilities.
  • ○
    A culture shift is needed to ensure equity of access for all care home workers to professionally develop and enhance residents' care.
  • ○
    Participants believed that ECHO sessions were enjoyable and informative, and results indicate CHWs reflected and integrated learning into practice.
• What are the implications of this new knowledge for nursing care with older people?

  • ○
    To our knowledge, this is the first evaluation of ECHO specifically in a care home context.
  • ○
    The study is an essential first step to inform the wider implementation of ECHO in care homes.
  • ○
    Results indicate that those who participated in ECHO acquired knowledge that could positively impact on the quality of residents' care.
• How could the findings be used to influence policy or practice or research or education?

  • ○
    Resources are required to improve the IT competence and confidence of care home workers.
  • ○
    Findings suggest reducing the length of an ECHO sessions whilst retaining key elements of the structure. Care home ECHO sessions have been reduced from 90 to 60 min.
  • ○
    Larger‐scale research is required to determine the direct impact of ECHO on residents' quality of care.

1. Introduction

The complexity of the gerontological nursing needs of older people living in care homes have been well rehearsed (Barker et al. 2021). Residents do not always have access to specialist care and may experience long waits as older people living independently are prioritised (MA Education 2024; Genet et al. 2011). Care home workers (CHWs), referred in this study as carers, nurses and managers, who work in a residential or long‐term care facility, require a broad range of skills to deliver resident‐centred care and identify when specialist input may be required.

Due to international workforce recruitment and retention challenges, it is difficult for CHWs to attend educational opportunities (Scales 2021; Scottish Social Services Council 2021; World Health Organization n.d.). CHWs have also reported limited access to expert and secondary care support, which the COVID‐19 pandemic exacerbated (Fallon et al. 2020). Specialists have limited resources to visit older people in care homes and provide direct support to CHWs. Yet, access to both educational opportunities and specialist clinicians for CHWs is critical; studies have shown wide variability in residents' care when not driven by their need (Goodman et al. 2017). For example, services available to residents are influenced by commissioning, contract agreements and financing agreements between care homes and other providers. CHWs are in a prime position to provide or identify when specialist care may be needed by residents yet may not be equipped to do so. Delays in accessing specialist care are likely to impact upon residents' quality of life, as well as life expectancy (Care Quality Commission 2023).

Care home workers are often undervalued (Blanco‐Donoso et al. 2021; Bahn et al. 2020). Although older people in care homes often have multi‐morbidities and experience cognitive decline, the role of CHWs is often perceived as less skilled than those working in acute hospitals. This is likely exacerbated by the multiple disadvantages experienced by the CHWs. For example, most CHWs are women, earn low wages and reside in areas of high deprivation (Stevenson 2020). These disadvantages are compounded by limited access to educational opportunities (McGilton et al. 2020) due to internal factors, such as low literacy (Tadd et al. 2013), as well as external factors, such as variation in employers' access to training and education.

The use of Extension for Community Healthcare Outcomes (ECHO) has the potential to connect CHWs to specialist education to support the care of older people in care home facilities. ECHO is an educational platform that can develop workforce capacity in disadvantaged populations by leveraging cost‐effective videoconferencing technology (Project ECHO Northern Ireland, 2018–2020 2021). ECHO aims to connect practitioners to case‐based learning and expert support. ECHO sessions are organised via an ECHO ‘SuperHub’, an experienced ECHO partner that has been accredited to train a recipient organisation in the standardised use of ECHO. The SuperHub recruits and trains a facilitator within the recipient organisation (known as Hubs). The facilitator's role is to act as conduit between the SuperHub and Hub to ensure topic areas are relevant, to recruit and support expert presenters in the ECHO approach and to facilitate discussions during ECHO sessions. Both the SuperHub and facilitator manage recruitment to the ECHO sessions.

2. Background

ECHO was developed in 2007 to support the care of people living with Hepatitis C in remote areas and has since been used across many complex conditions in over 45 countries (Project ECHO Northern Ireland, 2018–2020 2021). ECHO sessions typically last 90 min, in which a ‘specialist’ (doctor, specialist nurse or other health and/or social care professional) delivers a brief presentation, and recipients then present an anonymised case study before both come together to share recommendations for best practice. A continuous loop of learning, mentoring and peer support makes ECHO unique compared to other online learning modalities (The University of New Mexico 2023).

A systematic review of the impact of ECHO found they improved participant confidence, changed behaviour, were cost‐effective and, in some studies, improved patient outcomes (Zhou et al. 2016). Included studies spanned acute hospitals, as well as primary care. However, only two of the thirty papers included CHWs, and the review was published almost a decade ago (Catic et al. 2014; McBain et al. 2019). An evaluation of 34 ECHO in Northern Ireland suggested that the model could result in increased knowledge, skills, confidence and self‐efficacy across all disciplines (Project ECHO Northern Ireland, 2018–2020 2021). This study also found reduced feelings of isolation, particularly among practitioners working in remote and rural locations (Project ECHO Northern Ireland, 2018–2020 2021). There is also evidence that ECHO can impact positively on healthcare professionals' learning including perceived knowledge and confidence to manage complex cases (Catic et al. 2014; McBain et al. 2019). Although the Northern Ireland ECHO evaluation included both urban and remote locations, it was conducted before and during COVID‐19 when the care home context was under significant pressure due to the high mortality rate of residents. The use of ECHO also aligns well with the national (Scottish Government 2022) and international (World Health Organization (WHO) 2022) healthcare policy agenda, which advocates enhancing the health of those who live in care homes, upskilling the workforce, interprofessional working and making best use of digital solutions.

There is a need to improve the care experience of older people residing in care homes. Despite the potential for ECHO to improve access to specialist knowledge to support residents' care there is limited evidence of its usefulness from the CHWs' perspective. There is a dearth of evidence around factors effecting the implementation of ECHO. Improvement interventions cannot simply be ‘lifted and shifted’ from one context to another, rather tailoring to the specific context is required (Skivington et al. 2021). Additionally, exploring the largely unheard voices of CHWs will provide insights into how ECHO could be successfully implemented within the care home context. Understanding the experience of individuals or groups is best explored through qualitative research (Creswell and Poth 2016).

3. Methods

This study aimed to explore the perceived impact of ECHO with CHWs, and factors that enable and inhibit implementation. The research questions were:

1. What are the experiences of ECHO for CHWs?

2. What factors enable and inhibit ECHO implementation in care homes?

3.1. Care Home ECHO Intervention

Project ECHO Care Homes was commenced by the Highland Hospice SuperHub in May 2023 led by a Project ECHO Development Lead (Highland Hospice 2023). Two ECHO Hubs (Hubs A and B) were established in two healthcare organisations in Scotland in May and June 2023. The SuperHub trained a facilitator in each Hub in the ECHO approach (see Figure 1: Care Home ECHO model). Facilitators liaised within and between care homes in their catchment area and liaised with the SuperHub to agree topics, recruit presenters, secure dates and provide support to presenters during sessions.

FIGURE 1.

Care Home ECHO Model.

Technical support was delivered remotely between the SuperHub and Hub and between the Hub and care homes. Technical support within care homes was dependent on local CHWs with IT skills. The chosen technology was Microsoft Teams, a virtual meeting environment. The ECHO facilitator at each Hub shared the Microsoft Teams link with the specialist presenter (for accessing the session remotely) and the care home managers who then shared with their CHWs. Some CHWs attended on care home premises, and some from home.

For each ECHO session, facilitators identified a CHW to present an anonymised case relevant to the topic and specialist presenters were experts within their healthcare organisation. For example, the Stress and Distress Specialist Team gave an overview of the topic, the facilitator aided a question‐and‐answer session, a care home worker presented a case of a resident living with dementia who was experiencing increased agitation, and both expert and care home staff identified ways in which to manage the case and similar cases.

Care homes were reimbursed by the SuperHub at a rate of £15 per attendee per ECHO session as an incentive to ‘earn while you learn’. Care homes used the funds to either pay for additional hours for those who accessed the ECHO whilst off shift or to backfill for CHWs attending during their shift.

3.2. Settings and Context

Both Hubs (different healthcare organisations) included care homes within urban and rural locations. Sessions were delivered every 2 weeks in the afternoon or evening. Timing of sessions and topic areas were determined between the ECHO Facilitator and care homes in each organisation. ECHO sessions in Hub A (n = 5) and Hub B (n = 4) covered different topic areas (see Tables 1 and 2). There was one presenter and one facilitator for each session.

TABLE 1.

Hub A (14 care homes) session topic and numbers of participation.

Session topic	No. of care home staff participating
1. The pandemic as a catalyst for positive change	33
2. Frailty and delirium and working with the wider multidisciplinary team	29
3. Safe care—what does it mean and how does it influence decision‐making?	28
4. Complex decision‐making towards the end of life—when to transfer?	15
5. Meaning, purpose and re‐capturing enjoyment at work!	15

TABLE 2.

Hub B (10 care homes) session topic and numbers of participation.

Session topic a	No. of care home staff participating a
1. Navigating complexity: palliative care for residents with complex needs and decision‐making	16
2. Dignified end‐of‐life care: understanding terminal agitation and recognising the dying process	18
3. Comprehensive care: addressing frailty, delirium and collaborating with the multidisciplinary team	9
4. Empowering choices: advance care planning for care home residents	7

^a Data extracted from iECHO (data repository for ECHO system).

3.3. Methodology

A qualitative approach was adopted to allow exploration of the impact of ECHO from the CHWs' perspective, including their insights into what enables and what inhibits programme implementation, and why.

3.4. Recruitment and Data Collection

Attendance data were counted via the number of individual Microsoft Teams connections per ECHO session. Although the total number participating in the ECHO session was 120 for Hub A (Table 1) and 50 for Hub B (Table 2) in the iECHO system 44 CHWs were registered for Hub A and 32 for Hub B, suggesting individual CHWs attended more than one session. Additionally, CHWs explained that often more than one CHW would be accessing the ECHO via a single computer, especially if attending in the workplace, which suggests these figures are an underestimation of attendance. All registered CHWs (n = 76) plus facilitators/presenters (n = 11) were sent a Participant Information Sheet inviting them to participate in a post‐ECHO focus group. Separate focus groups were held for CHWs (July and August 2023) and ECHO facilitators/presenters (September 2023) to encourage openness of responses.

All participants consented online prior to focus groups. A topic guide was used to facilitate the discussions and recordings were transcribed by the research team and stored in the University's secure online repository. Participants were sent a £20 supermarket e‐voucher for their time spent participating in the focus groups.

3.5. Participants

The first three focus groups were for CHWs (n = 13, response rate = 17%) with facilitators/presenters attending the fourth group (n = 6, response rate = 54%) (Table 3). Focus groups 1–3 were conducted at various dates and times to accommodate as many CHWs as possible. Focus groups lasted between 58 and 83 min.

TABLE 3.

Description of focus group participants.

Focus group	No. of participants	Professional group
1	4	2 Care assistants, 1 nurse, 1 care home manager
2	5	3 Care assistants, 2 care home managers
3	4	4 Care home managers
4	6	2 Facilitators, 4 presenters

3.6. Ethical Considerations

The study was approved by the University Research Ethics Committee (Application ID: ETH2223‐1216). Participants were asked not to identify their care home location. Data from focus groups were anonymised to protect participants' identities.

3.7. Data Analysis

Data from focus groups were analysed thematically using the Bruan and Clarke six‐step approach (Braun and Clarke 2021): (1) recordings were transcribed verbatim and reviewed multiple times for data familiarisation; (2) transcribed data were coded using NVivo; (3) initial codes were clustered into provisional themes through a process of development, revision and refinement; (4) themes were reviewed in relation to codes and the entire data set to consider alternative options for pattern development; (5) a detailed thematic framework was produced with descriptions of themes; and (6) an analytic narrative was developed to illustrate the data, incorporating data extracts. Analytical processes were discussed regularly among the research team and an audit trail maintained for transparency. Participants were given anonymised codes using FG1‐4 to denote focus group number and P1‐6 for participant number.

4. Findings

Three main topic areas were identified: (1) Perceived Impact, (2) Factors Enabling ECHO Implementation and (3) Factors Inhibiting ECHO Implementation (Figure 2).

FIGURE 2.

Visual Representation of Findings.

4.1. Perceived Impact

4.1.1. Satisfaction With ECHO

All participants reported satisfaction with ECHO mainly due to the opportunities for learning and the relaxed learning environment.

From a learning point of view, it's excellent. FG1, P1.

I really enjoyed it. I found it quite interesting. FG2, P2.

I had a really positive experience. I felt like as a group they were all very welcoming. FG2, P4.

4.1.2. Feeling Valued and Confident

Participation in ECHO instilled confidence and a sense of pride among care home staff.

I think it does make them feel valued. It makes them feel part of something. FG3, P2.

This newfound confidence extended to a more efficient use of local health and social care support systems.

I think it gives people that confidence. I don't know if any of my nurses would think to phone up the local hospice if they were stuck with something, especially if it was out of hours. FG3, P2.

4.1.3. Benefits for Residents

A key benefit from participating in ECHO was the practical application of new knowledge, which could enhance the care experience of residents living in care homes.

I think just knowing that the staff are improving their knowledge and skills and, and they've got an interest in the topics which is obviously going to benefit the residents as well. FG2, P1.

So, it's going to help my residents and their families and everyone that I provide care for. FG1, P4.

CHWs shared specific examples of content directly impacting the care of residents, by shifting perceptions and understanding of key challenges in care homes.

I got to understand the key concept of what a perfect death is… They don't want to go to the hospital. So, it's very good, we now know when and how to assist them to die peacefully and erm, also to, to die by their own choice. FG1, P4.

Don't know how to deal with somebody that's, that's delirious and, and acting in a way that you know, they find strange. And umm, there's, there's loads of techniques out there! FG1, P1.

4.1.4. Networking

Participation in ECHO provided CHWs with opportunities to network, develop contacts and form connections with other professionals.

I think just knowing, and getting to know people, contacts, resources that are out there. FG2, P1.

Developing these supportive relationships could instil a sense of community and reduce feelings of isolation.

It gave me that sense of, as everyone's been saying throughout, the sense of a community and a support network and that, you know, someone always had your back. And we're all in the same boat, essentially. FG2, P4.

Networking across multiple services highlighted both positive and negative aspects of practice and potential areas for improvement.

Like different people have different situations to deal with. And you think, God, mine's not that bad. FG1, P3.

In some cases, participation in ECHO resulted in CHWs forming lasting personal and professional relationships.

I keep in touch with one of the other managers from the other care home who I met through ECHO, and we've now become really good friends and quite often phone each other about different things. FG2, P5.

Connections made during ECHO could also result in more integrated ways of working between care homes.

I learned about processes that were more streamlined between a certain care home … I was then able to take that back and look into that more and about how we can then make improvements. FG3, P4.

4.1.5. Learning and Development Opportunities

Participation in Project ECHO was considered supportive of professional development and registration.

It's going to help me through my revalidation (UK Nursing and Midwifery Council Requirement) and through my practice as a nurse in care homes.

Some CHWs engaged with further education and training following ECHO.

Our staff nurse had presented … she's done a presentation on a case study (an ECHO session) … and now off the back of that, she's doing further training to improve her knowledge. FG2, P1.

‘All teach all learn’ ethos is integral to ECHO which seemed to encompass attendees and presenters, with presenters gaining insight from case‐based learning, and having more understanding of the learning needs of staff and the care home context.

I actually learnt from them about some of the challenges they've got and also some interesting kind of cases …was able to kind of reflect on that. So, I actually learnt from them, which I wasn't surprised by. You always learn something when you teach. FG4, P1.

4.2. Enablers of ECHO Implementation

The themes for the topic area of enablers were administration and technical support, engagement, scheduling, convenience and flexibility, ECHO approach and protected time.

4.2.1. Administration and Technical Support

The SuperHub played a crucial role in supporting programme implementation by providing facilitators at local Hubs with administrative and marketing support, and intensive training.

The team are always on hand, and they have definitely helped us … you know, the communication outwards and using our system. FG4, P6.

The immersion training …you're fully immersed in all things ECHO for up to three days but there's something about that next step … like where we're learning from each other and how to try and roll this out in the most kind of meaningful way. FG4, P6.

Facilitators could provide technical support during sessions, with contingency plans for technical malfunctions.

I had excellent technical support from [Facilitator] which made a huge difference and allowed us to use some of the interactive things quite well. FG4, P1.

Sharing devices appeared to instil confidence and provide mutual support for CHWs engaging in ECHO.

I really do think you need two or three so they can support each other. So, they don't feel that they're going on the screen themselves, that they don't feel that they're being like hung out to dry and stuff like that. FG1, P1.

4.2.2. Engagement

Incentives for participation were perceived to be beneficial from those participating. However, not all payment incentives were claimed suggesting that financial incentives, by themselves, were insufficient.

I don't know if that's another like indication that actually that, even with funding, you're not going to engage with people that wouldn't already want to just come along and learn. FG4, P6.

Promotional strategies were multiple to improve engagement and offer equity in learning opportunities.

We went to like a care inspectorate event … we went to care home manager forums … we went to collaboration events … and just delivered almost like an elevator pitch of what ECHO is … we tagged that along with a form to have your say, tell us what you want. FG4, P6.

You're always going to have your hard‐to‐reach people … and I get that the efforts absolutely have to be focused on that. But at the same time, we need to push where doors are open. FG4, P6.

4.2.3. Scheduling

Scheduling aided engagement with ECHO, for example, out of hours sessions and having different time slots.

I liked the time that it was on' cause it was, you know, out of working hours, which, you know, and it doesn't suit everybody, but it suited me. FG3, P1.

4.2.4. Convenience and Flexibility

The online learning format was well received by learners as it provided access to learning at any time and any place.

So, they could use it there, or they could do it from home, or they could do it from wherever, you know, so there were options for them, and I think that's really important. FG2, P5.

Online learning reduced the need for travel, which had particular value for rural‐based CHWs.

I used to do the palliative care champions… it was a big commitment to diary off basically half the day because the time it took to get there, to get back, to attend it because it's quite a distance away.… I suppose with ECHO, you've got, you can just basically set aside an hour and a half and it's there, it's just on your desk. FG2, P1.

4.2.5. ECHO Approach

The inclusive approach to learning involving multiple care home services was reported to provide learners with new insights and awareness of different care management approaches.

They want to get together and have a chat and share experiences with each other and ask them, you know, how did you manage with this person with delirium? How did you manage with this person who was dying? … What agencies did you pull in that would help? FG1, P1.

Multidisciplinary team involvement was reported to have provided opportunities for knowledge exchange and an appreciation of the roles and responsibilities of colleagues.

Nurse could put in their input, but then a carer could also put in their side of the story. So, you could get the full picture. FG2, P4.

The case‐based learning approach facilitated reflections shared in an open and collegiate environment.

I think that obviously the case studies were helpful to kind of, I suppose reassure everybody that we're all, you know, facing the same situations and it was helpful to have that spoken about in an open kind of forum … I think that the people who attended felt like part of the solution as well. FG3, P1.

The interactive learning environment provided learners with opportunities to open‐up conversations and discuss situations informally with immediate feedback.

The fact that it's interactive, that makes a huge difference to me personally. I'm not very much one for sitting and reading books or sitting doing a module online, but the fact that you've got the opportunity to ask questions and network … that's invaluable. FG3, P2.

Presenters played a key role in facilitating learning using a non‐judgemental approach resulting in greater learner confidence and engagement.

It's just like about making it clear from the beginning that there are no questions, or a silly question … there's no wrong answers … I think it's just about letting people know that it's fine to speak up and they won't get shot down in flames or checked if they get it wrong. FG4, P4.

4.2.6. Protected Time

There were multiple comments around the necessity to protect time for ECHO. Some CHWs attended in their own time, whilst others during work time. The latter were often interrupted from the ECHO session to provide care. Care home managers could be pivotal in providing time and access to the training.

The manager made sure that we were all up to date with what we needed to know. And made sure that we had reminders when the training was on. And the manager gave us plenty of time off to do it and just said you can come into work so it's accessible here if you're struggling at home. FG2, P3.

We have to get the managers on board to give them the protected time. FG1, P1.

4.3. Inhibitors of ECHO Implementation

The themes for the topic area of inhibitors were digital skills and access, learner diversity, duration, limited protected time and workforce challenges.

4.3.1. Digital Skills and Access

Not all care home staff were comfortable using technology to participate in sessions.

The other thing it's, I suppose I'm not good with technology, so online to me is horrendous, and I just freeze up … I want to say it scares the hell out of you, but that's how I feel. FG1, P2.

Staff often chose to keep their cameras off which limited engagement and interaction.

I think engagement is really difficult online and there's a lot of kind of cameras off, not much input. FG4, P1.

Older CHWs were perceived by some participants to have lower‐level digital skills compared to younger colleagues, so requiring additional support.

It's just that kind of that technology barrier I think because we've got quite a few kind of older staff that need a lot of support with that. FG2, P1.

Sharing of devices, perhaps due to a paucity of technology in some care homes, posed barriers for ECHO facilitators and presenters recording attendance.

Quite often I'll find that, I'll think, oh, this is poorly attended, but then afterwards, I'll find out there's maybe been eight or nine sitting round the same device. So, it's the tech they don't have. FG4, P4.

As well as technical confidence and competence, some CHWs suggested issues with poor internet connectivity posed additional barriers to participation.

The only downside is we live in the north of Scotland, very remote, so, you know, your internet access is your biggest problem. FG2, P5.

4.3.2. Learner Diversity

CHWs occasionally reported being unfamiliar with proposed subject content and what an ECHO would involve. There was variation of perceived difficulty in understanding the content.

I think the staff, and I hope they won't mind me saying, were coming back and saying, oh, I don't know what that's going to be about. So, they needed maybe just to make it a wee bit more explainable to what was going to be talked about. FG2, P5.

A key consideration was pitching the presentation at the right level with the right content for a diverse audience. A pitch that was too high or too low, risked disengagement, so content needed to accommodate all CHWs needs (e.g., nurses, carers, senior carers).

The thing I found challenging was the real mix in the group. So, you had individuals from carers right through to people who were quite senior … So, you didn't want to be too complicated that people wouldn't engage, and you didn't want to be too simple that people would think oh she's patronising us. FG4, P5.

Sometimes the pitch was too high for some CHWs and so failed to address real practice concerns, as well as undermining learner confidence.

The folks that were on it were consultants, you know, these guys were top of their game … how on earth is one of my carers going to have any idea, because this is going over my head. FG1, P1.

4.4. Duration

Whilst ECHO have a specified format, some CHWs felt that the sessions were too long (1.5 h) and could be shortened and/or recorded. There was a perception that sessions were sometimes unnecessarily expanded to fill the scheduled time.

Sometimes I've been to some of the sessions where it's felt like it's had to be dragged out to meet the time scale that has been allocated … I wonder if there's such a thing or a potential for an ECHO bite size… I know it's quite prescriptive ECHO in terms of there's this amount of time for this and this amount of time for that. FG3, P1.

You know, half an hour is probably more doable for people to be honest. FG3, P3

4.4.1. Limited Protected Time

Protected time was an issue both for those at local Hubs who were taking on additional roles to implement ECHO (i.e., facilitators and presenters), as well as for CHWs participating in sessions.

We don't have that kind of designated project ECHO team … we've absorbed this project over and above like our full‐time jobs. FG4, P6.

The need for protected time was particularly difficult given the workforce pressures on care home staff. Care of residents had to be prioritised over training.

When there's people wanting to go to bed or running riot in the hallways, look, you have to go and help. FG1, P3.

There was also a suggestion from some carers that qualified nurses were prioritised over them to attend ECHO.

I think that's, it's, it's a bit of a cultural thing because of the hierarchy in care. If a nurse says they need time off the floor for an hour, they'll get the time off the floor. But if it's a carer there's a huge amount more pressure on them to stay on the floor and keep looking after the residents, particularly if you're running a bit short staffed as well. FG1 P2.

4.4.2. Workforce Challenges

Issues with staff recruitment, sickness absence and post COVID‐19 fatigue in care homes impacted engagement with ECHO.

I think the biggest barrier at this moment in time is, excuse my language, but people are knackered. There's a fragile staffing. When people do get downtime, they don't want to go and link back into work. FG3, P1.

Contributing to the staff workload were existing statutory and mandatory training demands, so the non‐mandatory ECHO sessions were not able to be prioritised by managers.

For the sake of argument, my training is 67 courses in a year. It's only 52 weeks in a year, it's like, and then to have this on top of it, it would be difficult. FG1, P1.

People don't have to turn up, they can make that active choice, well, you know, and there's no jeopardy for me in terms of not complying with registration. FG3, P1.

However, other participants suggested that linking ECHO to mandatory training and regulatory compliance might be a way forward.

If we were to take it to another level … if we could demonstrate through regulatory activity that by participating in ECHO and the associated outcomes that would help from a scrutiny and assurance perspective when it comes to care homes, you know, with their inspections and then also the connection to SSSC (Scottish Social Services Council). FG4, P6.

5. Discussion

This evaluation found that access to learning and specialist knowledge obtained via ECHO had a positive effect on the ability of CHWs to meet the complex needs of older people living in care homes. This included CHWs from remote and rural areas who face additional challenges to access learning opportunities. CHWs reported high levels of learner satisfaction, in line with earlier work in Canada, which found that 86.1% of participants agreed or strongly agreed that ECHO sessions met their expectations (Lingum et al. 2021).

Novel findings included perceived benefits to residents' care including an enhanced understanding among CHWs of choices around death and dying and insights into why older people may present with challenging behaviours and how to manage these. A similar project conducted in England during the COVID‐19 pandemic found that ECHO sessions provided clinical and psychological support to CHWs particularly around death and dying (Westerdale‐Shaw et al. 2021). A prospective cohort study of ten ECHO sessions in twenty care homes in Ireland found an increase in adherence to patient transfer wishes and advance care planning (Dowling et al. 2022). Additionally, evidence from a US pilot study using ECHO in care homes to manage dementia‐ or delirium‐associated behavioural challenges found improved resident outcomes, including a reduction in hospitalisations (Catic et al. 2014). Our study both aligns with the literature, supporting that ECHO can be a useful approach to enable CHWs to access education and specialist knowledge to support residents' care.

The experiences shared in this evaluation suggest ECHO sessions enabled CHWs to feel valued and confident; specifically, CHWs having the confidence to contact professionals in other health and social care services following an ECHO to discuss residents' care. Other networking opportunities were realised; this study found that relationships were built between participating CHWs from different care homes. Previous work has identified the concept of a ‘sense of family’ (Beattie et al. 2023). However, our study findings suggest this sense of family between HCWs could be extended from within individual care homes to across different care homes. The latter aligns well with community of practice theory which is a key educational principle underpinning the ECHO model—emphasising the importance of ongoing participation with and learning from each other (Socolovsky et al. 2013). CHWs need to have the same level of esteem as other health and social care providers. The perceived low value of work and status of CHWs can have negative effects on their wellbeing and subsequent job retention (Henderson 2001). This suggests that ECHO can potentially aid recruitment and retention of this reducing workforce.

A key enabler was the administrative and technical support provided by the SuperHub which included facilitators' training, liaising with care home managers and promoting and scheduling ECHO. However, technical support did not extend directly to CHWs, and some reported fears and anxieties round using Microsoft Teams. Some CHWs created informal technical support by logging in with peers and managers who were more confident and competent with the technology. These limitations in technical confidence and competence are well known and are a barrier to the key role digital technologies could play in the learning and development of the social care workforce (Oung et al. 2021). This study suggests that technical support for CHWs would enhance their skills and confidence and be needed to sustain the ongoing delivery of ECHO. Digital literacy could be supported by formalising a buddy system across the care home sector, using a peripatetic IT facilitator to support care home staff and/or ensuring ongoing support from ECHO facilitators. The Super Hub is currently exploring the role of a peripatetic IT facilitator to travel and support CHWs face to face.

Despite support from the ECHO SuperHub and a small financial incentive, engagement with the ECHO sessions was low. This is a well‐known challenge in the care home sector due to stretched workforce resources. A more fruitful strategy might be to make the right thing (attending ECHO sessions) the easy thing to do, with several participants making practical suggestions such as reducing the duration of ECHO sessions to create ‘bite‐sized’ or mini‐ECHO. Shorter ECHO sessions may be easier to attend and aid retention. There is consensus in education literature that concentration diminishes over time (Lamba et al. 2014). Testing ‘bite‐sized’ ECHO for care home staff would be useful, taking care to keep all elements of the ECHO structure. The structure and approach of an ‘all teach, all learn’ ethos (Nhung et al. 2021) appeared essential to the care home ECHO success.

This study also highlighted the challenge of learner diversity, and how to pitch ECHO sessions at a level, which accommodates diversity. Some participants found content too complex, whilst facilitators worried oversimplification would be offensive to CHWs. Revision from CHWs feedback has enabled a refocus of topic content on symptom control/management and less clinical content to avoid medicalising their important social care role.

Participants in this study found being able to access educational and specialist advice via technology convenient, particularly those who worked in remote and rural areas. Virtual access to ECHO also enables equity of access to specialist support and educational opportunities. There are also potential environmental benefits, such as reducing the need to travel, subsequently decreasing associated carbon dioxide emissions (Morcillo Serra et al. 2022).

6. Limitations

Despite various recruitment strategies the number of CHWs participating in the study remained low. More than half of the participants were care home managers; therefore, findings are unrepresentative of the care home workforce. Participants were self‐selecting, and it is possible that those who attended ECHO were a more motivated population. Despite these limitations, the findings resonated with the existing literature and CHWs at a National Care Home Conference in 2024 (Beattie et al. 2024).

7. Conclusions

Ensuring access to specialist knowledge and expertise for CHWs who support older people living in care homes is challenging. This study recognises that ECHO has the potential to partially address these challenges, with CHWs expressing general satisfaction with its use. The identification of important enablers and inhibitors of using ECHO in care homes can inform future implementation.

Author Contributions

M.B. was the P.I. The study was designed by M.B., K.M. and N.C. M.B. and K.M. obtained ethical approval. M.B., K.M. and N.C. designed data collection tools. M.B. and K.M. conducted online interviews and transcribed them. M.B. and K.M. conducted the qualitative data analysis. M.B. drafted the paper, and all authors contributed to revisions and agreed to the final version.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.