Hearing and vision care provided to older people residing in care homes: a cross-sectional survey of care home staff

Hearing and vision loss in older adults is challenging for them and can also affect other health related outcomes, including an increased rate of cognitive decline, increased risk of falls and reduced quality of life [1‐3]. If care homes are to improve such outcomes then effective hearing and vision care should be provided to older residents. This is likely to be reliant upon good staff training on how to provide routine care, identify problems being experiences by residents, instigate effective aid management and ensure provision of regular hearing and vision tests. However, it has been found that there are many barriers to providing quality ear and eye care in care homes, including staff knowledge, residents cognition, management of assistive devices and the environment [4]. To overcome these requires understanding of current practice, including the barriers to implementing best practice and how they might be overcome.

In England there are around 400,000 older people residing in care homes [5], with 75% of these individuals estimated to be living with some degree of hearing loss [6] and around 50% with some degree of vision loss [7]. However, these sensory impairments often go undetected or are poorly managed, resulting in residents living with limited hearing and vision capabilities [8]. The consequences can significantly negatively affect residents’ quality of life; this includes physical health, mental health, and opportunities for social interaction [3, 9, 10]. Despite these acknowledged impacts there is still a lack of focus on sensory impairment identification and management in older people in care homes. Evidence suggests that this can be due to the common perception by care home staff and residents that hearing and vision loss are normal aspects associated with ageing [8]; This contributes towards hearing and vision loss becoming hidden health issues within this population.

A recent review has found that there are other barriers in care homes that contribute to the poor identification and management of hearing and vision loss in residents [4]. These include a lack of care home staff knowledge, poor management of assistive aids (e.g. hearing aids and glasses), limited access to specialist services such as audiologists and optometrists, under-use of screening tools, an unsuitable care home environment, and residents’ reduced cognitive capabilities [4]. A number of studies aimed to increase knowledge in staff using methods such as educational videotapes [11], workshops [12], or by attaching instructions about insertion and maintenance of hearing aids to the inside of residents’ wardrobes [13]. Training residents to manage their own devices has also been applied in one identified study [14]. Whilst these practices were reportedly beneficial in increasing staff and residents’ knowledge, how and why these have been effective is largely unknown. Furthermore, screening tools such as the Nursing Home Handicap Hearing Index [15] test and the Minimum Data Set [16] have been used by staff to assess residents’ sensory difficulties, but the review found that use of such instruments was problematic in practice [4]. Most research to date has focused upon highlighting the barriers and facilitators in care homes, with minimal research evaluating interventions aimed at improving current best practice [4].

Other evidence also reveals reluctance among residents to use their prescribed assistive aids and reduced ability to manage their own aids without assistance [11]. Whilst the emphasis is mainly on staff and professionals providing the required treatment, care and support, family members can also assist with management of ear and eye care [17, 18]. Hearing and vision charitable organisations have produced guidelines in effort to overcome some of the barriers to best care [6, 19]. However, more evidence is required to underpin such guidance.

Whilst it is important to have a range of practices available to effectively support residents with sensory impairments, it is also important to ensure that care home staff are readily aware of best practice and what might be practically implemented in their place of work [20]. They must also be sufficiently knowledgeable regarding what interventions they might readily implement and how to do this [21]. Improved care home staff knowledge of different hearing and vision conditions might assist with identifying what each resident specifically struggles with in everyday life, and thus what practices would be most beneficial. In addition, staff should know how to correctly clean and maintain hearing aids and glasses to ensure they are functioning correctly and can therefore be used to best effect [6, 19].

It is important for staff to understand how to effectively and efficiently improve current hearing and vision practices in care homes. However, the everyday practices used in care homes are unknown. The aim of the study described in this paper was to identify the practices care homes in England currently use and the level of knowledge staff have when caring for residents’ ears and eyes. All care homes in England have their quality of care rated by the Care Quality Commission. We have included care homes with different ratings as this will ensure the study includes the different standards of care homes across the country. By highlighting the practices most and least used and the gaps in staff knowledge, we can improve ear and eye care in this vulnerable population. To address the study purpose, we aimed to:

A total of 400 survey questionnaires were returned from staff working in 74 care homes across England.

In our cross-sectional study exploring hearing and vision care practices in 74 care homes across England, 400 care staff participated. Our study results showed that whilst some practices known to support residents hearing and vision [4] are commonly adopted by care homes, others were reported as being rarely found to be used. Practices commonly reported to be used include; recording sensory loss in residents’ care plans, annual professional vision tests, regularly checking hearing aids and regularly checking glasses. The majority of respondents also reported having quiet areas and well-lit rooms in their care home. These responses show that some practices suggested by existing guidelines are being adhered to [19]. However, there are certain practices which are known to assist with residents’ ear and eye care that were reportedly rarely used, including use of screening tools for both hearing and vision, hearing assessments by audiologists, and access to other assistive devices. This reveals that interventions aimed at improving practice, including use of screening tools as identified through the scoping review [15, 16], are rarely being implemented in practice. Our analysis also showed that there is more support available to identify and manage residents’ vision than hearing. As the study assessed which practices found to affect ear and eye care are adhered to in care homes, participants responses revealed that there are more vision practices being adhered to in practice when compared to adherence of hearing practices. However, both hearing and vision of care home residents can be neglected, with some screening tools, additional assistive devices and professional assessments not commonly used/provided.

Participants also stated that their knowledge was lacking in certain areas. Firstly, the majority were not confident in identifying and managing both hearing and vision impairments in their residents, which could contribute to the poor care of residents hearing and vision difficulties in care home residents [21]. This further highlights, that despite interventions aiming to improve knowledge in staff being reported as effective [11‐13], these have not been implemented effectively into practice across the country. In addition, audiology services were commonly reported as not being readily available to residents, suggesting this may be a further reason for the poor identification of hearing impairments in residents [6]. Whilst optometry services are commissioned to provide annual assessments in care homes in England, as confirmed in this study, audiology services are not commissioned or funded to conduct assessments in care homes and has evidently had an effect on how often these are carried out [24]. The poor adoption of some prescribed aids (i.e. hearing loop systems), and the reported limited access to other assistive devices to compensate for hearing or sight loss also suggests that residents may not be using devices that can improve or compensate for their sensory impairment. This can be another reason for poorly managed sensory impairments in residents [25].

Hearing aids and glasses were checked regularly by staff but the majority stated that they are not entirely confident in how these aids should be cleaned and maintained, and in particular hearing aids. This suggests that guidelines and interventions aimed at improving aid management need to be formally implemented, making this mandatory and increasing support for their acceptance in practice [6, 19]. So, whilst checked, these aids may not be functioning as they should be, resulting in residents still living with the effects of sensory impairments. This suggests that staff might need enhanced training to provide a sufficiently skilled service. The vast majority of respondents also stated they would like more information on how to identify and manage both hearing and vision loss, highlighting a need amongst all staff for further training in more than just aid management. This suggests that care home staff and researchers should prioritise providing training for care home staff in ear and eye care; this could also include developing the skills and knowledge of a particular staff member within each care home to create hearing and vision care champions within the team who can address ear and eye concerns effectively and efficiently.

The high level of uncertainty amongst health care assistants and those identifying as ‘other’ on the practices used in care homes, including whether screening tools, other assistive devices and professional assessments are used in their care home for both hearing and vision, also suggests that there may be a poor level of shared communication about these practices. Health care assistants, including the senior health care assistants who identify within the group ‘other’, are often the first point of contact for residents and so need to be made aware as a priority. A champion amongst the health care assistants in ear and eye care may aid to reduce this lack of shared communication within the care home, and increase knowledge amongst these groups of the practices available within and outside of the home that could be useful when providing personal cares. However, no difference in knowledge of hearing and vision difficulties and how to manage them was found between job role, emphasising that hearing and vision loss knowledge is the same despite job role.

Homes catering exclusively for people with dementia reported the lowest willingness among residents to use and also care for their prescribed aids, which reveals that cognition may play a significant role in residents’ ability to use and maintain ownership of their aids, suggesting that staff in homes for people with dementia may need to have heightened awareness and training. Respondents from dementia only homes also report a lesser likelihood of audiologists providing annual assessments in comparison to general residential or nursing homes. As cognitive impairment is known to be a further barrier to effective identification and management [26], these results seem to suggest that staff and other professionals need to be trained specifically in dementia care [27]. This may include providing training on how to recognise sensory impairments in those living with dementia and knowing the difference between what might be a sensory impairment and what is dementia. Also, how to screen those with memory difficulties for hearing and vision difficulties and how to encourage assistive aid use.

The level of knowledge of hearing and vision care among all respondents was similar irrespective of their job role, length of time working in the home, care home type or size of their home. Therefore, whilst knowledge of staff was found to be poor for identification and management of both hearing and vision loss, this was the same regardless of participant or care home characteristics. The results show that it is mainly the respondents’ knowledge of whether certain practices are adopted in their care home that differs dependent on the different demographic factors. This suggests there is a universal need for training and awareness of the importance of shared communication regarding practices available within the care home to support with residents’ ear and eye care.

The study results suggest that to improve hearing and vision care practices a focus on improving certain aspects is required. These include; having a range of assistive devices available in care homes such as hearing loop systems and magnifying glasses, having screening tools that all staff can use in their daily practice to identify those at risk, building stronger links between care homes and external professionals, and training care staff to increase their knowledge of how to both identify and manage hearing and vision impairments effectively. With certain responses affected by the individual profiles of the respondents, it also highlights a lack of standardised procedure and shared knowledge across care homes and their staff. Therefore, improved communication and best practices for hearing and vision care need to be implemented to ensure effective hearing and vision care is provided by all care staff. This could be achieved with a change in policy and guidelines that inform managers of the best practices [4], and the importance of informing their staff of the practices available to care for residents hearing and vision within their home.

Our study results indicate that whilst some services are available in most care homes for ear and eye care across England, others are not as frequently implemented or that staff are unsure of whether such services are available or not. This highlights the underuse of the certain services and implies patchy implementation of the practices which could significantly benefit residents hearing and vision capabilities and improve mental and physical health. Consequently, this infers that best practice for ear and eye care in care home residents can be improved, and this evidence identifies specifically which practices should be targeted, including screening tools, annual hearing tests conducted by external services and having access to various devices. In addition, staff knowledge shows room for improvement, with the majority of staff wanting more information on how to care for both hearing and vision in their residents. This study confirms the need for better support for care home staff so that they can provide optimum ear and eye care including services provided by others external to the home. It also identifies a need for further research to explore how quality services can be both provided and sustained over time. Due to the limited evidence, the implementation of mentioned practices should be evaluated by research on the effectiveness and benefit for residents with regard to hearing and vision. This could also focus on the improvement of mental and physical health and residents’ quality of life.