Dignity for care workers
Improving the value and status of care work to support mutual respect between people who provide care and people who receive it.
If staff do not recognise dignity, if they feel taken for granted, if their self-esteem is dented, then it becomes more difficult for them to deliver dignified care.Tadd et al, 2011
Dignity for care workers in practice
Commissioners and providers should:
- Allocate adequate resources to produce the best outcomes for people using services. Low pay is unlikely to motivate workers or improve the status of the work. The alternative may be costly in terms of recruitment, retention and reputation.
- Ensure that staffing levels and time allocated for home care visits allow workers to carry out their work properly in a way that respects the individual.
- Promote autonomy for care workers, moving away from task-centred and time-restricted work schedules and reflecting the wishes of people using the service.
- Ensure care workers are provided with the training they need to do their job well. Training should be structured, ongoing and largely work-based, focused on the needs of the people using the service and provided, at least in part, by people who use services and those with experience of frontline care work.
- Ensure that care workers are supported by other professionals (e.g. social workers, community nurses, occupational therapists, dieticians, continence advisors) who can provide practical and emotional support, develop their knowledge and skills, and enable them to cope with difficult situations e.g. challenging behaviour and family conflict.
- Respect the experience and the knowledge care workers have of the people they work with.
- Assess applicants’ attitudes at interview and regularly monitor thereafter.
- Provide a clear definition of the care worker role and a clear career path, from induction onwards, associated with training, learning and skills development. The framework for progression should reward achievement and be linked to pay and other benefits.
- Promote and reward quality time spent on compassionate, person-centred care. Ensure the complaints procedure also encourages compliments.
- Provide strong leadership, regular supervision and ongoing practical and emotional support to frontline care staff.
- Provide training and awareness-raising, to reduce any negative effects of cultural and racial differences (including language and accent) between care workers and people receiving the service.
- Ensure that abuse against care workers is taken seriously and that policy and procedures, as well as training, supports people to understand and respond to challenging behaviour in positive ways.
- Involve care workers in day-to-day decision-making and service improvement.
- Ensure workers do not feel isolated, either by working in isolated services or, for home care workers and personal assistants, by the nature of their work. Promote connections with other community services and peer support groups.
- Promote awareness of how to raise concerns about safeguarding and whistleblowing.
A care worker is a person who is employed to support the independence of individuals in need of that support due to disability, illness or frailty. Care workers provide a range of services including practical assistance, personal care, and emotional support. They can provide these services in residential or nursing care settings, in the person’s own home or in the community. Care workers can be employed directly by social services, by private and voluntary organisations or by individuals who receive a personal budget or fund their own care. A number of different terms are used to describe this role including: care assistant, support worker, personal assistant and, in the US, care giver, nursing aide and paraprofessional.
What others are doing – ideas you could use
- Invite staff to specialise in an area of practice and increase their skills
- Work with professionals to develop care worker skills
- Value and recognise the work that care workers do
Care Quality Commission – what the regulator saysOpen
The CQC is the independent regulator for health and social care services. It has set out Essential Standards of Quality and Safety (CQC, 2010) for all those registered to provide health and social care services. There are 28 outcomes relating to the different aspects of care provision.
What CQC outcomes say about care workers:
- Outcome 12 requires registered providers to have ‘effective recruitment and selection procedures in place’ and to ‘carry out relevant checks when they employ staff’. The recruitment process should ensure that staff are suitable. CQC suggests that providers consider whether prospective workers are ‘honest, reliable, trustworthy and treat the people who use services with respect’.
- Outcome 13 seeks to ensure that there are sufficient staffing levels to meet the needs of people using the service. This is vital for care worker wellbeing because if the demands on them are too high the quality of their work and possibly their interactions with individuals may suffer.
- Outcome 14 requires registered providers to provide the right support to workers ensuring ‘that staff are properly supported to provide care and treatment to people who use services….that they are properly trained, supervised and appraised and [enabled]… to acquire further skills and qualifications that are relevant to the work they undertake.’
Dignity for care workers – key points from policy and research
- Despite some of the negative aspects of care work, many workers report high levels of job satisfaction (Skills for Care, 2007; Robinson and Banks, 2005; Lucas et al 2008).
- Stress and low morale, resulting from the way that care staff are treated, can have a direct impact on service quality and cost (Rose et al. 1998, Hatton et al 2001,Thomas and Rose, 2009; Bromley and Emerson 1995).
- Stress and low morale, reported by some care workers, can lead to high sickness rates and staff turnover (Thomas and Rose, 2009; Hatton et al, 1995).
- High staff turnover can be very costly due to wasted training resources and recruitment costs (Hatton et al 2001; Mittal et al 2009).
- Workers who feel that they put more into the job than they get out are more likely to detach themselves emotionally from their work leading to the ‘depersonalisation’ of people using the service (Thomas and Rose, 2009).
- Care workers sometimes experience verbal or physical abuse from clients or their families (Skills for Care, 2007).
- Workers who are already experiencing stress may be more likely to respond negatively to challenging behaviour (Gilbert and Osborne, 1989 in Thomas and Rose, 2009).
- One of the key components of ‘Developing social care: service users’ vision for adult social care’ was to ensure better funding and resourcing of social care and social care workers (Beresford et al, 2005).
- Job satisfaction and retention of care staff can be directly affected by status, inclusion in decision-making, respect for the role, good management and supervision (Stone, 2001).
- Care work would benefit from pathways for career development supported through induction, training and supervision (Eborall and Griffiths, 2008; Land and Himmelweit, 2010; Manthorpe and Spencer, 2008; Stone and Wiener, 2001).
Dignity for care workers – what the research and policy says in detailOpen
Much has been written about dignity in care, and rightly so, but the dignity of those who provide services has been relatively overlooked. There is very little in the literature that refers directly to care worker dignity but some interrelated problems have been identified that impact on the wellbeing and dignity of the social care workforce, and are relevant to the care worker’s perception of dignity in their role. These issues overlap and can exacerbate each other:
- limited resources and low staffing levels
- low status and pay
- staff feeling stressed, rushed and overworked leading to low morale, burnout and potentially poor standards of care
- limited or poor quality training
- lack of supervision and support
- experiences of racism and other discrimination
- high levels of sickness increasing pressure on the remaining staff in the workplace
- high staff turnover resulting in wasted training resources and high recruitment costs
- lack of career pathways.
Much evidence about care work stems from US studies, but issues appear to be similar in the UK. However in the UK, evidence has been drawn, particularly with regard to worker stress and burnout, from those working in learning disability services. Levels of pay and training are often higher for this group than for other care workers (Hussein and Manthorpe, 2010). This is potentially relevant as care provision for older people increasingly involves meeting complex needs and responding to challenging behaviour.
The move to more personalised services may increase the number of care workers (support workers or personal assistants) employed directly by people who use services or their carers. This can raise work condition issues . Whilst job satisfaction rates may be higher the work may be poorly paid, there may be less clarity over the role and boundaries, and workers are at risk of isolation (Manthorpe et al. 2010). This may be further complicated when family members are being employed (Manthorpe et al 2011), particularly if they do not have high or equal status in the family.
Resources, low status and pay
There is one time in my life, every month, when I not only feel slightly guilty, but embarrassed as well. That’s when I pay my personal assistants...the value of the work they do for me bears no relation to how much they are paid.Simon Heng, Community Care: 2 October 2008
People at the frontline of health and social care services are crucial to the provision of good quality care. Yet care workers are among the lowest paid in our society, even when supporting people with high needs such as people with dementia (Hussein and Manthorpe, 2011). In 2009, Skills for Care reported that pay remained low and suggested that this raises ‘questions regarding how much this committed workforce is valued by society’ (Skills for Care, 2009).
People who use services have highlighted the issue of poor-quality staff and have called for better funding and resourcing of social care and social care workers (Beresford et al, 2005). Current policy, however, is focused on increasing productivity and there are reports of care workers having their wages cut in many areas (BBC, 2011).
Despite its increasing importance, care work continues to hold little status. This is not helped by some negative portrayals in the media (Wild et al, 2010) and some views that care work is women’s work, unskilled and an extension of domestic labour (Aronson and Neysmith, 1996). The ‘National survey of care workers’ found that ‘63 per cent of care workers thought the public did not understand much about the work they do, and just 39 per cent thought their work was valued by the public’ (Skills for Care, 2007).
Mittal et al (2009), in a study of retention and turnover in the US, found that: ‘by far, the issue that was voiced most vociferously for leaving a direct care job was the perceived lack of respect for the work’. The lack of recognition and respect for care work has been highlighted in several other similar studies (Kemper et al, 2008; Hatton et al, 1995).
Despite some of the negative aspects of care work, many workers report high levels of job satisfaction (Robinson and Banks, 2005; Lucas et al 2008). The ‘National survey of care workers’ (Skills for Care, 2007) found that: ‘Nine out of ten care workers’ jobs made them happy’. Workers reported that the work was enjoyable and that making a difference to people’s lives was rewarding. They also liked the work because it fitted in well with other responsibilities.
Stacey (2005) suggests that if staff are respected and have dignity this may mitigate against the possible negative aspects of the role: ‘Dignity has intrinsic value for the worker but it also serves to mediate the obvious constraints of poor pay, job insecurity and emotional/physical strain that often accompany paid care work. Although in the long run, the sense of dignity may not prevent worker turnover or burnout, in the short term dignity keeps workers on the job.’
Workload stress, low morale and burnout
It is, of course, important that the recruitment process ensures that care staff have the right attitude and values in the first place. Further investment in staff through induction, training and supervision as well as appropriate workloads, is important in maintaining a good quality workforce.
In examining the reasons why people’s experiences of receiving care services can sometimes be so poor, researchers have looked closely at the relationships care workers have with both the people receiving care and their employers. Some studies of care work for people with learning disabilities (Thomas and Rose 2009, Bromley and Emerson, 1995, Gilbert and Osborne, 1989) have shown a direct co-relation between staff behavior - resulting from stress and low morale - and the quality of service provided. Similar studies for older people’s services are less common. Tadd et al (2011) report that NHS studies since 2003 demonstrate a co-relation showing higher levels of staff satisfaction relating to better patient experience.
Job satisfaction is very important. ‘Dissatisfaction occurs if people feel unappreciated, are poorly managed and have to put in extra unpaid time to deliver what they perceive to be an adequate service’ (Manthorpe and Spencer, 2008). If an individual feels that they put more into their work than they get out, then the imbalance can lead to ‘emotional exhaustion’ and ‘burnout’. This can lead to the person detaching themselves from their work emotionally, investing less in working relationships, depersonalising service users and lacking the ability to empathise. (Thomas and Rose 2009; Buunk and Schaufeli, 1993). Wardhaugh and Wilding (1993) suggested a possible theory of ‘neutralisation of moral concerns’. This can ‘place residents beyond the bounds of normal, acceptable behaviour, allowing abusive behaviours to be justified and perceived as legitimate’ (Marsland et al (2007).
Aronson and Neysmith (1996) refer to ‘depersonalising policies’ and the exploitation of care workers that may put at risk the people receiving care. They were critical of task-focused approaches to care which fail to acknowledge the personal and human aspects of care work that both improve job satisfaction for workers and quality of service for the person receiving the service. They noted, however, the inseparability of the practical and emotional aspects of care work and found that ‘workers accomplished their tasks in the context of relationships with personalised knowledge of their clients’. The early, in-depth, study by Foner (1994) found a tendency to reward those who work quickly and complete tasks over workers who take the time to provide support with compassion and kindness.
The concept of depersonalisation is central to the dignity debate as it appears to directly oppose person-centred care. ‘Seeing the person’ has repeatedly been advocated as a way of ensuring good quality interactions between frontline staff and people using services. Furthermore, this idea is particularly relevant now when personalisation is a key driving force for change in health and social care provision.
Institutionalisation, where the regimes and routines of the home or services are placed above the needs of individuals, can be both a result and cause of depersonalisation. The culture of organisations that provide social care and health services will influence the attitudes and behaviour of staff and the quality of care provision. We have known about the risks of neglect and poor practice associated with total institutions since Goffman published Asylums in 1962 (Manthorpe and Stanley, 2004).
At their most extreme, cases of neglect and abuse in care homes have been highlighted by the media. Often, organisational culture or institutionalisation is found to be at least partially the cause.
The study of the care of older adults in acute NHS trusts (Tadd et al, 2011) found that ’the majority of staff are motivated to represent patients’ interests but these motivations are frequently compromised by systemic and organisational factors.......Furthermore, within the observed wards, local cultures have developed, often in the context of untenable staffing levels and a strictly demarcated and hierarchical division of labour’.
The culture of an organisation may promote institutionalised care and may cause ‘the practices of well-intentioned staff to deteriorate’, it may also allow intentional abuse to go unreported (Marsland et al, 2007). The Rowan report (Commission for Health Improvement, 2003) followed allegations of physical and emotional abuse of patients by care staff. Investigations by strategic health authorities following this identified a number of risk factors:
- low staffing levels and/or high use of agency staff
- geographically isolated units
- wards with poor physical environments
- weak/poor management
- lack of nursing leadership
- lack of policy awareness (Benbow, 2008).
A move away from institutionalised care for people with learning disabilities well over a decade ago was intended to reduce the institutionalisation of both residents and staff and consequently to improve the quality of life for people using the service. The model, based on ‘normalisation’ encouraged community participation and meaningful activity. For older people, the increasing size of some care homes and the limited staff resources raises questions about how personalised care can be promoted and institutionalised practices avoided. Such impersonal models of care are not considered acceptable for people of working age and their continued acceptance supports arguments about discriminatory attitudes towards older people. The Centre for Policy on Ageing (Clark, 2009) found evidence of discrimination against older people in service provision both in terms of the funding allocated and the opportunities offered. This study found significantly lower levels of support for older people and restricted social opportunities (Clark, 2009). The reduced resources available for older people may affect the ability of workers to provide the kind of care that they would like to.
Staff recruitment and retention
The high turnover of care staff in some services can be very costly, disruptive to continuity and affect the quality of care (Kemper et al 2008). Retention of care work staff is critical to the quality of care provision. The dignity in care literature frequently highlights the importance of staff ‘seeing the person’ for what they are, understanding their personal history and building up positive relationships. If a service has a high staff turnover or relies heavily on agency or temporary staff then such relationships will not be easy to develop (Cornes et al, 2010). Lucas et al (2008) have argued that ‘the impact of turnover on service users will be greater than in other sectors of the economy because of the value that service users place on continuity of care’.
Pay is by no means the sole motivator for care workers. A Skills for Care report highlighted a number of factors that impact on recruitment and retention including ‘pensions, guaranteed hours, sick pay, holiday entitlement, flexibility of working patterns and other factors such as quality of management and factors such as status and negative perceptions of the sector’ Lucas et al (2008).
Stacey (2005) argues that worker autonomy ‘promotes a sense of ownership over the standard of care and, by extension, a sense of dignity for the worker’. Mittel et al (2009) also recognise that the development of relationships between those providing and receiving care is important for staff retention. They found that those who stayed in their jobs longer were workers who had formed relationships with the people for whom they provided support.
Service users have highlighted the problems of excessive use of agency staff (Beresford et al, 2005). Furthermore, it may be expensive and inefficient to run a service with a high staff turnover; resources may be wasted on repeated recruitment and on induction and training for people who subsequently leave. Unfortunately, services that fail to address the issues that face the care workforce are likely to enter a vicious circle with high costs for training and recruitment (Mittal et al 2009). This can result in a burden on permanent workers leading to higher stress levels and ‘burnout‘, making it more likely that they too will leave or become ill. Studies examining the issues of high turnover, job satisfaction, stress and morale for care workers have identified a number of relevant factors. They include:
- low pay, heavy workloads, a lack of role definition and no clearly defined career structure (Eborall and Griffiths, 2008)
- lack of recognition, deficiencies in other staff (e.g. competence, turnover rate), the emotional impact of the work, violent or aggressive service user behaviour, conflict of work with personal or family demands, uncertainty concerning job tasks and limited opportunities for personal advancement (Hatton et al, 1995)
- lack of practical and emotional support and lack of involvement in organisational decision-making (Hatton et al, 1999)
- lack of time available to work with the individual, lack of skills or knowledge, lack of managerial support, problems in communication between staff, general lack of resources (Bromley and Emerson, 1995)
- home care staff not being paid for mileage and time between visits, insecure working conditions due to lack of guaranteed hours, supervision being carried out in unpaid time, limited training budgets (Manthorpe and Spencer, 2008).
All of these issues may have an impact on individuals’ perception of whether they themselves are treated with dignity and ultimately whether they choose to stay or leave care work.
Abuse of care workers
Wild et al (2010) found that fear of assault at work is a significant cause of stress for some care workers. The ‘National survey of care workers’ found that ‘care workers were quite likely to have suffered some of verbal or physical abuse from clients or their families at some stage’ (Skills for Care, 2007).
People displaying aggression should be supported so that the risk is minimised and reasons for their behaviour explored. The person’s predicament, their inability to communicate their needs or indeed the way they are treated by care staff may be the root causes of their anger. Developing an understanding of the dynamics that result in challenging behaviour, and how best to respond to individuals in distress, may empower care workers and increase their confidence.
Several older studies, outlined by Bromley and Emerson (1995), examined the effects of challenging behaviour on the attitudes of care workers towards the people they support. Foner (1994) examined abuse against care workers from nursing home residents in terms of the impact on worker behaviour, and therefore the service quality. Foner suggested that employers may have a tendency to focus on strict recording of abuse against people using the service whilst overlooking that against care workers. The study recorded incidents of physical, verbal and sexual abuse against workers. Such abuse was often perpetrated by people lacking mental capacity but in some cases it was reported that the person was aware of what they were doing. Workers responded in different ways to this abusive treatment, whilst many coped and responded well, others admitted to responding with physical or verbal abuse and some were observed to be asserting control over residents or demonstrating indifference. The types of care worker behaviour reported relate directly to the types of mistreatment reported in the study of ‘dignity in care’ as focused on in this guide:
- isolating people
- denying food
- taunting and mocking
- ignoring calls for help
- not respecting privacy
- using people’s personal possessions without permission.
There has been some argument that workers who are already experiencing stress may be more likely to respond negatively to challenging behaviour (Gilbert and Osborne, 1989 in Thomas and Rose, 2009). Emotional and practical support from employers, as well as training, may enable care workers to deal with abuse, stress and workload in positive and constructive ways that do not result in negative responses towards people using services.
Induction, training and supervision
There are increasing numbers of people using care services and higher levels of disability. The need to increase the skills of the workforce to equip them to face these increased challenges is widely recognised (Wild et al, 2010). Training is frequently recommended as a means of both supporting and developing the workforce and of improving service quality. Furthermore, support and career development opportunities are likely to improve the status of care work making it a more attractive career choice.
A number of writers have highlighted the benefits of providing a pathway for career development for care workers supported through induction, training and supervision (Eborall and Griffiths, 2008; Land and Himmelweit, 2010; Manthorpe and Spencer, 2008; Stone and Wiener, 2001).
In a review of work-based learning in the UK health sector, this approach was seen as a way of supporting the changes in health and social care as developments lead to more personalised and home-based services (Hardacre and Schneider, 2007). The practice of external professional staff supporting and sharing skills with residential care staff has long been highlighted as good practice (Rose et al, 1998). As part of their continuous professional development (CPD), care workers can learn from the professionals with whom they come into contact such as speech and language therapists, dieticians and psychologists. Skills for Care provides a brief guide to CPD for social care workers Developing yourself - a brief guide to continuing professional development (CPD) for adult social care workers ) in which it suggests a number of methods for development including in-house courses, job-shadowing, secondment, mentoring and coaching.
The impact of language and cultural difference
The DH survey on dignity in care (DH, 2006c) highlighted concerns about language and cultural differences between staff and the people they support. Racial and ethnic differences can be the cause of misunderstandings and some studies have found racist attitudes and discrimination towards care workers (Aronson and Neysmith, 1996; Foner,1994; Hussein et al, 2010; Stevens et al 2011).
From the US, Stone and Dawson (2008) went further, arguing that: ‘The wide variation in ethnicity and cultures represented among staff in long-term care settings heightens the potential for tension, miscommunication, and conflict between caregivers and care recipients, between peers and between supervisors and [careworkers]’.
There is great reliance on migrant workers in care work in some parts of the UK and particularly in London and the South East. Government plans to reduce immigration may present recruitment challenges for the sector (Skills for Care, 2011). Hussein et al (2010) found that people using services and carers ‘valued international workers, although some voiced concerns about language abilities, turnover and cultural differences’. The study also noted that ‘some international workers’ integration, skills and understanding of cultural needs improved dramatically over time’.
Researchers have recommended that employers acknowledge and address the issues that may arise from racial, ethnic and cultural difference (Hussein et al, 2010). Stone and Dawson (2008), in the US context, recommend improving the English language skills and ‘building cultural competence knowledge and skills into formal and on-the-job training’.
Some studies have looked at what would improve working conditions for care workers.
Across settings, workers called for more pay and better work relationships including communication; supervision; and being appreciated, listened to and treated with respect.Kemper et al, 2008
Pay is, of course, a key issue but other things may have the potential to improve job satisfaction for care workers. Workers have stressed the importance of being listened to. Staff often have an in-depth knowledge about the needs and preferences of the people they work with; their insight is important and should be respected. Stone (2001) drew attention to the importance of status, inclusion in decision-making, respect for the role, good management and supervision, arguing that these principles can directly affect job satisfaction and retention of care staff. She referred to a US training programme specific to dementia care that ‘demonstrated significant improvement in the wellbeing of residents’ who were cared for by staff who had received the training. However, as Hussein and Manthorpe (2011) have shown, staff working in dementia services in the UK have the least access to training.
Another study by the Paraprofessional Healthcare Institute (Dawson 2007) advocated, in the context of the US, for nine essential elements of a quality job:
- family-sustaining wages
- affordable health insurance and other family-supportive benefits
- full-time hours if desired, stable work schedules, balanced workloads, and no mandatory overtime.
- excellent training that helps each worker develop and hone all skills – both technical and relational – necessary to support long-term care consumers
- participation in decision-making, acknowledging the expertise that direct-care workers contribute, not only to workplace organisation and care planning, but also to public policy discussions that impact their work
- career advancement opportunities.
- linkages to both organisational and community services, as well as to public benefits, in order to resolve barriers to work
- supervisors who set clear expectations and require accountability, and at the same time encourage, support, and guide each direct-care worker
- owners and managers, willing to lead a participative, ongoing ‘quality improvement’ management system – strengthening the core caregiving relationship between the long-term care consumer and the direct-care worker.
Over the last decade there have been attempts in parts of the US to address the issues of low pay and status of care work through several measures including: improving worker pay and fringe benefits, developing career ladders and improving training (Stone and Wiener, 2001).
Unison, the British trade union, in the context of personalisation, recommended:
- Career structures need to be developed which will offer a reason to stay in social care for those workers coming in through apprenticeships. Care is too important to be treated as a job of last resort.
- This must include personal assistants – good employers look after the development as well as training needs of their staff. This should be funded by the Government as part of a national concern with creating a sustainable workforce.
- Pay systems must reward greater training and responsibility.
- There should be structures which allow older and more experienced care workers to help develop the skills and confidence of the next generation of workers, as happens in Finland.
- The skills involved in care work must be fully recognised and valued. With the boundaries between their respective tasks blurring, health and social care workers should have opportunities to work and train more closely together. (Land and Himmelweit, 2010)
A UK study into care home workforce development suggested ‘a grading structure with remunerative incentives to attract more young people into care work’ (Wild et al 2010), but there are clearly challenges in doing this at a time of wage reductions and decline in terms and conditions in some social care services.
Acknowledging that the challenges facing the care workforce may have been exacerbated by the outsourcing of social care, the Improvement and Development Agency, now the Local Government Group, made a number of recommendations for commissioners. These include:
- Avoid rigid, task-orientated commissioning and contracting which can have a negative impact on service quality and staff morale.
- Take a broad approach which includes an assessment of the impact on job satisfaction, team ethos, cross-organisational working and recruitment and retention.
- Provide development and career paths for all staff that match their aspirations and meet the longer term needs of the local community.
- Attract, develop and retain excellent managers and inspirational leaders in both outsourced services and in the authority.
(Manthorpe and Spencer, 2008)
It is clear from the evidence that the treatment of care workers is relevant to the quality of care service provision. Respect for the role along with appropriate levels of reward, good training supervision and leadership may improve the wellbeing of the care worker and the quality of the service they provide. Ultimately this may result in better outcomes for those receiving services, particularly those outcomes that lead to people feeling that they themselves have been treated with dignity and respect.