by Maya Haddad, Dr Alison Beck and Dr Katherine Belton
But the fragmentation of care home provision, both in terms of different types and sizes of providers of services and the complex process of commissioning and purchasing services, poses significant challenges to ensuring consistent support for staff in care homes.
We spoke to people working in the care home sector in south London during the summer of 2020 to explore the extent to which they feel emotionally supported at work. We also interviewed stakeholders representing various agencies and organisations that support the sector to find out what could be done to improve the emotional wellbeing of this vital workforce.
‘Just get on with it’
We heard that those working in the care home sector face a multitude of stressors that include working long hours for low pay, difficulties in managing the behaviour of residents, not having enough time for self-care or to “reboot” and feeling that, despite the difficulties, you are expected to “just get on with it”.
Most managers we interviewed described unmanageable workloads, consisting of myriad organisational demands, that often led to staff working well above their contracted hours. Several described being on call and available 24/7, including during periods of leave.
Some described feeling that you constantly have to ‘cover’ yourself and ensure you are prepared for upcoming checks. Many registered care managers (RCMs) spoke of feeling in the line of fire and being the first to get blamed when things go wrong because “it is easier to blame one person than an entire system”.
During the pandemic, managers were left feeling physically exhausted and emotionally depleted. They described having to deal with various logistical pressures, such as sourcing food for residents and PPE for staff, not being able to get hold of GPs, and having to accommodate residents who had been discharged from hospital with Covid-19.
As workers increasingly became sick or feared coming into the workplace, there were inevitable staffing challenges. Some likened their jobs during the pandemic to war-time conditions and commented that, “people say this is like the war, but at least during the war you could have a hug”.
Managers explained they had continued to present at work to role-model that doing so was safe, and would fill in gaps absent staff would otherwise attend to, such as cleaning and shopping. Some continued working remotely while isolating with symptoms to feel they were still “doing something”.
There were also emotional demands, such as having to reassure anxious staff and keep morale up by role-modelling calmness and confidence.
Lack of emotional support
Similar challenges were described by care home staff, including long working hours, restrictions on when to take annual leave, managing challenging behaviour of residents and, during the pandemic, having to manage with a lack of supplies for both staff and residents. Staff felt their role, often complex and comprising aspects such as enabling residents and upholding their human rights, was overlooked and underappreciated by the public, especially compared with health workers’.
Staff told us about the emotional toil of working during the height of the pandemic and managing their fears of becoming ill with Covid-19 or infecting loved ones (some of the staff we spoke to identify as Black, Asian, or minority ethnic and told us that they and their families felt at particular risk). There were also challenges in managing stress, confusion and fear among residents, who often could not grasp why restrictions were being imposed on them.
Neither RCMs nor frontline staff felt there was adequate support to help them cope with the highly emotive material and pressures they are frequently subjected to, both day-to-day and during the pandemic. The majority of people we spoke to felt the sector’s culture does not generally invite staff to discuss the emotional impact of their work and reflect on how they are coping.
While RCMs told us that they have an ‘open door policy’, this was not always understood by their staff. Some did not feel supported, respected or cared for by the management team or organisation, especially during the pandemic.
One staff member felt she had been “left here to die” due to lack of perceived support from senior management. The care home staff we spoke to had mixed experiences with RCMs throughout their careers, with some being more supportive than others, but emphasised the sheer influence that RCMs have on creating a particular working culture.
Need to join up
The care home sector’s governance and financial structures are complex and fragmented. With care homes largely operating as independent private businesses, this brings challenges around ensuring consistency across the sector in how staff in care homes are paid and supported.
This also creates organisational boundaries that inhibit the sharing of learning between care homes. During the pandemic, local RCM digital forums acted as fundamental information-sharing platforms and provided managers with a designated space for peer-to-peer support, as well as helped to encourage a consistent approach to how common challenges should be addressed. We think this is a positive step and encourage the expansion of similar forums beyond the pandemic.
Many health and social care commissioners described a disconnect not only within the care home sector, but also between health and social care. One spoke of a tension of cultures and a “clash of different worlds” between the two sectors due to a differing ethos in the provision of care.
Some mentioned the level of investment in staff training and development in the health sector and told us “far less” was invested in the care workforce. One commissioner we interviewed pressed for a “bigger national debate” about the lack of career pathways for care home staff, especially within the context of Brexit and its potential impact on numbers of qualified nursing staff.
We heard there can sometimes be a disconnect “between what’s happening on the frontline in care homes and in strategic planning”, which can leave RCMs feeling disillusioned by, and distrustful of, regional and national public health strategies. We were told this can also create an impression that things are continuously being ‘done to’ care homes, which can make staff feel disempowered.
We were told that coproduction can lead to greater buy-in among staff and managers, helping to increase loyalty and the benefits associated with it, such as retaining corporate knowledge and increased productivity.
The need for cultural change
Our findings indicate a need for cultural change in care home practice. Most care home managers and providers agree that retaining staff to ensure consistency of care is essential to high-quality provision.
Staff need to feel invested in any improvements of the care home. They need to be asked for their input and have their views heard in the realisation of local improvements in care practice.
Commissioners can influence their relationships with RCMs, ensure these are supportive and recognise the difficult work that they do, providing additional resources where possible. To embed a ‘just culture’ throughout the care sector, RCMs need to feel that their jobs are manageable and their practice defensible.
A combination of training and ongoing support is proving useful and needs to be maintained post-pandemic. Care home providers may be amenable to learning from one another about best practice to improve care and cost effectiveness; this includes performance improvements that can be achieved with a well-supported workforce. Sharing good practice in an appreciative, mutually-supportive forum is particularly important for smaller care home providers who typically lack opportunities to collaborate.
- Keeping Well online portal. We heard that staff working in health and social care want and need more psychological support, but often feel inundated with various digital self-help materials and find it difficult to navigate through these products. As such, we have developed an online portal for health and social care staff in south east London to enable free access to a range of digital health products and psychological therapy all in one place. The Keeping Well site features a live chat and phone function that enables users to be supported by assistant psychologists to locate the most appropriate resources and be referred for psychological support.
- Online community platform. Recent studies have shown the importance of social bonds in acting as protective factors during times of great stress. We need to build on this evidence of ‘what works’. Staff groups currently use social media and work closely together to support one another through such applications. However, these can be fragmented and some staff fall through the gaps, so we’ve focused our energies on bringing existing groups together to harness existing staff resilience and build across the sector in a more inclusive way. We are currently developing community platforms that aim to bring people of similar professional backgrounds and experiences together to support each other’s mental health, share learning and develop their skills.
- RCMs and their staff need regular 1:1 wellbeing conversations that specifically ask them how they feel, encourage them to reflect on their emotional wellbeing, as well as their practice and encourage change as a result.
- Staff need team wellbeing meetings to explore common issues, increase awareness and normalise the conversation around wellbeing at work.
- Buddying systems can enable staff to support each other through the challenges of their work.
- Develop career progression and opportunities across health and social care and to build shared understanding.
Maya Haddad is an assistant psychologist, Dr Alison Beck head of psychology and psychotherapy and Dr Katherine Belton clinical psychologist at South London and Maudsley NHS Foundation Trust