Exploring the perspectives of care at home staff supporting older adults with communication and swallowing difficulties

Abstract

More than 950,000 people receive domiciliary care in the UK from over 13,000 registered homecare providers employing nearly 809,000 staff (Homecare.co.uk. 2025). Incidence of stroke, dementia and associated communication or swallowing difficulties increases with age (WHO 2018). A paucity of research exists exploring the perspectives of care at home staff supporting older adults with swallowing (dysphagia) and communication (aphasia or dysarthria). The benefits of early identification, and risks from, reduced support are known (RCSLT 2021a) as are the current pressures and personal impact of delivering care at home (Feeley 2021). Taking a qualitative approach, using constructivist grounded theory and realistic vignettes, I interviewed 16 staff in one Scottish Health Board to understand how older adults with communication and swallowing difficulties are supported at home, to inform discussions around integrated care and staff support. Analysis of findings, including practical mealtime and communication strategies and AAC, led to the construction of a theory: the delivery of care at home to older adults with communication and swallowing difficulties is experienced by staff as an iterative process of ‘becoming’, ‘managing’, and ‘letting go’, actively negotiated with the person receiving care and influenced by factors of continuity, team, values, time, and attitudes. This theory is depicted in a new model, the Care at Home Infinity Loop. It further theorises that staff experience simultaneous loops throughout their unique care career. The study concludes that a process exists through which care at home staff learn and fulfil a unique, skilled role in supporting people with communication and swallowing difficulties; that stronger facilitation of process enabling factors and reduction of inhibiting factors may support staff, service users and the wider multidisciplinary team (MDT); there is a need for personal and professional support for care at home staff in this role and fuller collaboration as members of this MDT.