Doing, Being and Becoming a Valued Care Worker: User and Family Carer Views
Jill Manthorpe, MA
Jess Harris, MSc
Kritika Samsi, PhD
Jo Moriarty, BA, RMN
Abstract
This paper presents and discusses data from a study of the views of people using social care services and of family carers about their care workers, what they do that is valued, what are valued characteristics and how people become or are made ‘good’ care workers. It is set within the context of policy interest in England in values based recruitment as a means to address some of the problems in social care services arising from high levels of turnover and variable care quality. Such efforts to promote values-based recruitment have brought the question of values centre stage in social care in addition to their more established place in social work and other professions. The interviews with services users and carers (n=60) were conducted face to face in four local authority areas in England. Findings are that service users and carers value staff’s presentation and performance; relationships with care workers; but hold different conceptualisations of training as adding to their workers’ capability and approach. Values appear to be viewed as innate to individuals and not fostered by training. These suggest some differences between values that are integral to professional identities and those that are deemed important in care work.
Introduction
A recent Cochrane review observed ‘A key concern for managers and nurse administrators of healthcare settings is staffing’ (Hodgkinson et al, 2011, p.2). However, while aspects of staffing such as recruitment and retention receive substantial coverage in both policy and research terms, there is much less attention on what these staff actually do.Furthermore, for users of social care services it is perhaps not collective staffing or the ownership of the organisation that matters but their care worker, their relationship, their experiences and theirworker’s values. This paper presents and discusses data from a study that obtainedthe views of people using social care services and of family carers about their care workers, what they do that is valued, what are valued characteristics and how people become or are made ‘good’ care workers.It is set within the framework of policy interest in England in values based recruitment as a means to address some of the problems in social careservices arising from high levels of staff turnover and variable care quality.As such, it aims to contribute to the emerging literature on the meaning of care and what it means to those who deliver and receive it (Barnes 2012); an important debate in the UK and the developed world as populations age and female employment outside the home reaches high levels.
Background
The views of people using care services about their care workers have been seen as important to improving English social care services for over a decade. They have shaped the concept of user-desired outcomes, based on principles of ‘autonomy, choice, independence, empowerment and comprehensiveness’; and are underpinned by commitments to ‘rights and social inclusion’ (Hudson et al. 2005 4).In turn, these influence social care values such as ‘wellbeing, independence, social interaction andfeeling supported to have choice and control’ (NESTA, 2015, 16)although some have arged thatthe ‘care’ aspect of social care has become lost (Barnes 2012).
Banks (2012) points out that values are often defined in terms of beliefs, which reflects their status as being stronger than mere opinions or preferences. However, the values of social care workers (here meaning frontline care and support workers working in long-term care facilities,or in people’s own homes or day care services, not professionals such as social workers, occupational therapists, and so on) are often portrayed as personal and integral. This isin contrast to those held by social workers and other members of the caring professions,whose values are part of their professional identity (Bisman 2004) whichis learned, promoted, and shaped in training and practice.User views are also integral to the policy of personalisation which stresses that positive outcomes for care users will be fostered by choice and control over their care workers, who they are and what they do. Like the ‘modernisation’ of adult social care, personalisationplaces ‘increased emphasis on changes in the behaviours and roles of adult social care service users’ (Newman et al 2008, 531). At its most obviousis the legitimisation of people entitled to publicly-funded social care to become employers using the sums available to them in the form of Direct Payments to recruit, select, and employ their own staff. While personal budgets in the form of local authority ‘managed budgets’may modify this contractual relationship whenthe user or local authority takes the option ofplacingthe individual’s social care budget in the hands of a care agency, there remains scope for care users to make their preferences felt about the workers who provide their care, indicating their choices to the care agency (Baxter et al 2013). For some care users, the small amount of their personal budget and the effort entailed in employing a care worker means that they prefer ‘usual care’ from a care providing agency or business, which, as Woolham et al (2016) observe, may be the case for many older people.
However,little is known about the extent to which thesechoicesare themselves shaped by values, if at all.For example, do care users wish those they employ or manage to possess certain values or do they wish their care worker to share their own values?There has been some interest in exploring the theoretical concept of homophily(Kossinets and Watts 2009) to see if care users prefer to receive care and support from individuals who share their views about what is important to them.This was explored in respect of care workers by(Manthorpe et al 2012)in a small-scalestudy thatdid not explicitly focus on values as one of a set of possible influences on the care receiver and care worker dynamic.
Even less attention is paid to the choices and values exercised by those living in long-term care facilities, such as care homes. In policy terms, they are often viewed as a marginal group unable to live up to the autonomous expectations on which the policy of personalisation is built and thus for whom paternalism is acceptable (Barnes 2011).From this perspective, the views of care users seem to be dichotomised between those who exercise choice and those who are unable to do so and who are in need of care. Seen through this lens, care becomes the antithesis of choice.
A further tension emerges when the aspirations of care users are compared with those making decisions on their collective behalf.For example, a study by Davies et al (2015) found substantial disparities in the priorities placed on different needs-related outcomes by people with learning disabilities compared to the views of social services departments’Directors (p.203).“Psychological well-being” was the most important outcome foradults with learning disabilities but this was only of moderate importance to the Directors and in resource allocation.
The extent to which care users and care workers also share or differ in their notions about choices and values is often lost in consideration of the widespread problematic employment terms and conditions of care workers and ofeligibility and funding concerns. This is so powerful an effect that it can be hard to focus on one aspect and to separate individual values related to morality or personal beliefs from‘value’ in terms of cost, productivity, and efficacy. Drawing onpart of awider research study in this present paper (Manthorpe and Harris 2014)we focus on the individual level by exploring care users’ views of care workers’values and characteristics, as evident in relationships and receipt of care (see also De Silva 2011; Gridley et al, 2012; Demos 2014). Further papers have considered data from the study relevant to personalisation (Stevens et al, under review) and safeguarding (Manthorpe et al 2016).
In the English social care context, the meaning of the amorphous term values has been further complicated by increasing interest in ‘values based recruitment’ of staff.This stemsfrom an attempt to redress problems observed in diverse reports about the deficiencies of care services and health care provision (for example, Cavendish 2014). Social care employers have been encouraged to consider formal or informal expressions of job applicants’ values (see Skills for Care 2014a)in the expectation that widespread promotion and take-up of ‘values based recruitment’ approaches by employers will enhance recruitment of people with the values and skills required to deliver good care and furthermore will increase their retention.Evaluation of a pilot ‘recruitment for values’ toolkit (Goode 2014) (incorporating a personality-profiling questionnairebased upon psychometric profiling systems) concluded that this was a ‘promising’ approach, particularly ifa range of assessment techniques is combined to enhance the recruitment process. Skills for Care, the sector skills council,subsequently produced a values based recruitment and retention guide for employers (Skills for Care 2014b) and use of this was evaluated by Consilium (2016) who compared the views and experiences of employers who had used various values based tools for recruitment and appointment. This evaluation found a spectrum of impact and understanding with reference to a values based approach to recruitment and retention. Many employers said they found benefits in using a values based approach to recruitment and retention because they felt care staffworked better (i.e. in terms of sickness absence, punctuality, role related skills and overall) than staff recruited through ‘traditional’, non-values based methods.
However, there is little substantive evidenceabout users’values and how these might affect social care recruitment: most statements on social care valuesappear to follow a generally non-contentious view of values that overlooks the British cultural context (midway between traditional and secular-values but giving high value to self-expression, see Inglehart and Welzel 2010), political values, or family and cultural values. For example, Skills for Care depicts values as individual:
Values are the beliefs and attitudes of an individual, which influence their perception of what is good or bad (Skills for Care no date).
A further set of abstractions, referred to as the 6Cs (Care, Compassion, Competence, Communication, Courage, Commitment),are declared to be the values underpinning the English Department of Health’sCompassion in Practice commitment in health and social care (Department of Health 2012). Some of these might be considered to blur differences between values, skills, principles and activities; for example, ‘competence’ would seem more a skill than a value and ‘communication’ not a value but an activity.
Turning to Scotland, the Scottish Government states that, in a social care context, values are ‘our established ideals, the things that we regard as fundamental’ and lists these as being: respect, fairness, independence, freedom, and safety (Scottish Government 2014), distinguishing them from principles.
Nonetheless the term‘values based recruitment’ is being adopted across human services, especially within UK healthcare professions (Miller and Bird 2014;Power and Clews 2015). It is regarded as non-contentious, notwithstanding that inother employment fields there has been long-standing interest in defining values in terms of commitment to employers or sectors, which is a particular facet relevant to social care since this sector is largely dominated by the commercial sector rather than public service values (see Burns et al 2016). The values of large-scale owners and shareholders in this sector remain largely under-reseached, although recent work by Luyendijk (2015) on the banking sector is potentially relevant to all large corporations.
Nonetheless, for the benefit of this paper we adopted Lyons et al’s (2006, p.606) definition of values when scoping the area prior to the analysis:
Values are goals or criteria that we use to determine the desirability of certain actions or motives in our lives.
As they noted, the seminal work on values was undertaken by Rokeach (1973) who identified two sets of values: instrumental values,a person’s beliefs about the desirability of different modes of conduct, and terminal values, being the individual’s beliefs about the desirability of different end goals of existence (Lyons et al 2006, 606-07). This sets a conceptual framework for our discussion.
Study design and setting
The Longitudinal Care Work programme of work aims to increase understanding of the factors that facilitate or constrain recruitment and retention in the social care workforce in England (see Manthorpe and Harris 2014). In addition to240 qualitative interviews with social care workers and employers at two different time points approximately 24 months apart(ibid), we conducted a subset of interviews with service users and family carers about their experiences of using social care services;in particular we soughttheir views of their care workers. In total, 60 service users and family carers were interviewed across four different sites across England (see Table 1):a northern county council, a Midlands county council, a southern unitary authority,and a London borough, representing generally the spread of different socio-demographic characteristics in England. The final sample size was determined according to the principle of 'theoretical saturation', thus the interviews continued until no markedly new information came up (Green and Thorogood 2006), acknowledgingthat among people receiving care and support there are huge varieties of life histories and changing circumstances.
The sample of user and carer participants was recruited from a range of settings, including day centres, care homes, carers’ centres,and people using home care or support services in their own homes. These were run by a mix of local authorities, not-for-profit or commercial care providers. Participants were predominantly female (F=40, M=20).In terms of ethnicity, most participants described themselves as White British (46), five were Indian, two (white) Irish, two Arab, and single participants reported being from White Other, Pakistani, Sri Lankan, mixed Asian, Black Caribbean backgrounds. Table 2 presents participant characteristics by service user group and study site location.
1
Table 1: Study locations
Site / Users / Carers / TotalLondon / 15 / 3 / 18
Midlands / 11 / 0 / 11
Northern / 5 / 10 / 15
Southern / 13 / 3 / 16
Total / 44 / 16 / 60
Table 2: Characteristics of people using services and carers interviewed
Service User GroupOlder People (including people with dementia) (OP) (aged over 65) / 29
Mental Health / 15
Learning Disabilities (LD) / 15
Physical disabilities (non OP nor LD) / 1
Total / 60
Method
We asked service users and their family carers about their experiences of using social care services and to specifically discuss what factors were important to them,and why,about the care workers they encountered. Interviews were semi-structured with the topic guides covering their current and past care arrangements and reports of good and bad experiences of care. Details of their care workers were not collected and data were not triangulated between family carer and care user or between care worker and carer user or family carer.
Participants were interviewed at a venue of their convenience. In just over half of the interviews, this was their own home or care home. In addition,21 people were interviewed in avoluntary sector day centre and 8 carersataCarers’ Centre. All interviews, except for one in which notes were taken as there were difficulties with recording, were digitally recorded and transcribed verbatim.
Data analysis
Transcripts were subjected to thematic analysis (Braun and Clarke 2006), a rigorous process of identifying consistencies and trends in the data. The transcripts were read thoroughly before being systematically grouped into categories or core themes. Questions on the interview guide served as a starting point for these themes. A second researcher then examined the larger core themes in order to interpret the data and interpretive links with other categories. Themes were renamed or re-categorised iteratively as the analysis continued. Trustworthiness was ensured through multiple coding, detailed discussions at team meetings to seek out varied interpretations.Pseudonyms are used in the interests of confidentiality. NVivo 10 was used to manage the data during the analytical process and a master file was shared securely with the research team members.
Ethical considerations
Ethical approvals for this study were secured with research governance permissions acquired as necessary. The managers of the organisations we recruited from were contacted and also approved our making contact with care users and family carers, as we did not wish to interview people for whom such contact might be distressing or who were in crisis. We provided information sheets to all participants and assisted them with these where necessary and in the obtaining of informed consent. We offered a token payment to individuals and to the voluntary sector groups that allowed us to use their services as recruitment sources. Ethical considerations included details of our confidentiality policy and our need to inform authorities if we were made aware of potential serious safeguarding concerns.