Care home co-worker relationships: a key ingredient for care home quality

Abstract

The relationships that care home staff have with their co-workers are a key influence on the way they feel about their work and how they perform in their roles. This has a direct influence on quality of care and life as experienced by residents. However, care home providers face a challenge to promote co-worker relationships because: (a) the care home workforce often lack human resource oversight; (b) registered managers (and nurses), who often lack leadership training, are tasked with managing the working relationships of staff, the majority of whom are care workers of different ages, ethnicity and cultural beliefs; and (c) most (care workers) do not have any formal qualifications and are not routinely provided with the communication skills to facilitate collaborative working in dynamic and pressured climates. In this forum article, we consider these challenges and their implications for collaborative co-worker relationships, before highlighting opportunities for research, policy and practice. An important starting point is to focus on developing the leadership skills of staff at all levels and provide care workers with the skills they require to manage their working relationships and support them in their everyday work for the benefit of residents.

Introduction

Care home staff provide health and social care to society's most vulnerable people yet work in a sector known for its long hours, poor pay and low status. These same staff are a key influence on quality (Spilsbury et al., 2011, in press). Finding ways to promote staff wellbeing to offset the difficult climate in which they work is essential if quality is to be promoted.

The relationships that staff have with their co-workers have an important influence on their wellbeing (Haunch et al., 2021). These relationships influence how staff feel about their work and subsequently how they perform in their roles. Good working relationships offer several benefits: work is more enjoyable when staff have good relationships with those around them, staff become more innovative and creative, and they are more likely to feel a commitment to their work and support changes in service delivery and organisation implemented by care home providers. Good relationships are also often necessary for career development. Overall, people want to work with people they are on good terms with: staff should have good working relationships in supportive teams (Royal College of Nursing, 2015). However, most people encounter a mix of both positive and negative experiences in their relationships with co-workers (Beaulieu et al., 2005).

Collaborative co-worker relationships can be characterised as consistent positive social interactions that are based on and promote trust, respect and confidence among staff (Oppel et al., 2019). Collaborative working relationships fulfil a range of important functions such as mentoring, information exchange and social support. In health and social care, they are consistently linked to staff wellbeing, engagement in work and positive work outcomes, and can compensate for other difficulties that may arise in the workplace, such as staff shortages, increased resident need and unpredictable environments (Borrill et al., 2013). Conversely, non-collaborative relationships, such as a lack of positive social interactions, have been linked to communication failures, ineffective teamwork and impaired decision making, which has a negative impact on role performance and care delivery (Farrell et al., 2006).

The care home provider has a responsibility to promote co-worker relationships and this is often a component of regulatory inspections. For example, the independent regulator of health and social care in England (the Care Quality Commission), provides extensive guidance to help providers comply with regulations for staff wellbeing. In particular, they advocate for the widespread use of nationally agreed quality standards designed to preserve and promote co-worker relationships (Care Quality Commission, 2022d) and in turn to provide good and outstanding care. The Health and Safety Executive's management standards pertinent to workplace relationships states that care home providers should:

• • Agree policies and procedures to prevent or resolve unacceptable behaviour.

• • Promote positive behaviours to avoid conflict and ensure fairness, for example, implementing systems to enable and encourage supervisors to deal with unacceptable behaviour and that systems are in place to enable and encourage employees to report unacceptable behaviours (Health and Safety Executive, 2019a).

Regulatory bodies have the powers to act, such as refusing registration of services, should these elements not be in place or if social care providers fail to provide satisfactory evidence that they promote workplace relationships. Care home providers have particular challenges (and opportunities) for cultivating collaborative co-worker relationships.

In this forum article, we first consider these challenges and their implications for practice, before highlighting opportunities of promoting collaborative co-worker relationships for research, policy and practice. Our arguments are based on a review of the literature (see Table 1) associated with another project (Haunch and Spilsbury, 2021).

Table 1. Searching for relevant studies (Haunch and Spilsbury, 2021)

The challenges

Care homes are unique settings. The work is hard: staff are expected to provide care to highly dependent residents who have complex needs.

The context is different to health-care settings: there is rarely human resource (HR) oversight of staff; the registered managers (and nurses) have variable preparation for managing the care workforce, comprised of a mix of people of different ages, ethnicity and cultural beliefs; and many staff have not received any formal training or education and may not have any communication skills training to support collaborative working relationships. In addition, care workers only have one or two supervisors, usually a registered nurse, senior carer or manager, with the remaining staff as peer co-workers. The bulk of work organisation therefore occurs in the context of peer co-working and supervisor co-working relationships (Skills for Care, 2018). This makes it essential for collaborative relationships to occur. These unique challenges for the care home context are further considered below, along with opportunities for practice, policy and future research.

A lack of HR oversight to manage workplace relationships

The success of any business is dependent upon its workforce. This is even more so in a sensitive sector like social care that provides essential care and support for the most vulnerable members of society (Spilsbury et al., 2011). Having a strong, accessible and visible HR department to manage employee relationships is a key factor in achieving long-term success (Kabene et al., 2006). Health-care HR departments that implement practices such as: self-managing work teams, quality improvement teams, quality of work initiatives such as: policies on harassment, job swaps, employee suggestion systems and empowerment, in an environment that strongly values employee participation, empowerment and accountability, have a positive impact on performance, reduce organisational conflict and promote co-worker relationships (Rondeau and Wagar, 2001). The heterogeneity of care home service set up, however, can make HR provision a challenge.

Care home services (both nursing and residential) in the United Kingdom (UK) are mostly provided by independent care providers, made up of a mix of both for-profit (83% of the market) and not-for-profit businesses, but with some local authority provision (Comondore et al., 2009; Competition and Markets Authority, 2017). Care home provider organisations vary in size. Many are small providers with around 4,000 owning just one home run by an owner who is also the manager, to medium-sized local enterprises and large multinational chains (each owning over 100 homes in their portfolio). On a national basis, the largest six providers have a combined share of 11 per cent of all care homes and 17 per cent of care home beds (Competition and Markets Authority, 2017). This has implications for the way they operate. With the units of organisation small for many providers, many care homes do not have the resources to create a dedicated HR team. In larger companies care homes are geographically dispersed, so it is hard for HR professionals to consistently supervise staff or implement best practice (Comondore et al., 2009; Competition and Markets Authority, 2017; Pujol et al., 2021).

In the absence of HR departments, the local authority has a role in supporting providers by promoting integration, co-operation and partnership working (HM Government, 2014). As a major purchaser of care services, a region's local authority (or local government) has a duty to ensure the workforce are healthy, safe and meet minimum requirements (HM Government, 2014; Care Quality Commission, 2022a). Good commissioning, as outlined in legislation, should promote workforce development. Whilst there are undoubtedly pockets of good and outstanding care, support is not always forthcoming. Local authorities have limited budgets for commissioning social care services (e.g. day services, domiciliary care, residential care) and have experienced consistent cuts over the last decade (Care Quality Commission, 2017). As a result, many health and social care commissioners do not have robust systems in place to be able to shape the workforce proactively. Staff retention is an issue in many localities. This means workforce development is part of the owner/registered manager's role.

A lack of preparedness of registered managers to manage workplace relationships

The registered manager of a care home has substantial legal, managerial and commercial responsibilities. Their role varies depending on setting, but typically includes: ensuring the delivery of quality person-centred care, managing budgets, ensuring financial effectiveness, maintaining quality standards, creating partnerships with local community organisations, ensuring regulatory activity, such as personal care and medicine administration are within regulation, and providing information, advice and support to residents' families (Orellana et al., 2017; Skills for Care, 2021a).

As already highlighted above, many registered managers are also expected to take on HR tasks such as recruiting, training, supervising staff and ensuring conflict is minimised. Effectively communicating to promote collaboration and manage conflict in staff of different generations, cultures and social networks with various health and social care issues, requires careful skill and attention. Leadership skills are integral to achieving this (Orellana et al., 2017).

The regulator in England is committed to leadership as an important influence on care quality, stipulating that managers should have ‘the necessary qualifications, competence, skills and experience to manage the regulated activity’ (Care Quality Commission, 2022b). Managers often report feeling ill-prepared for their role and have called for more training in areas such as leadership (Orellana et al., 2017). Registered nurses are responsible for clinical oversight, and are often key leaders, as a care home manager or as a clinical leader (or both). While clinically prepared, nurses working in care homes may at times be the only professionally qualified person on a shift, with management responsibilities for staff at all levels within the organisation. They need leadership qualities, as well as overseeing the general facilities and running of the home. However, they also report being ill-prepared for leadership roles (Nhongo et al., 2018).

Whilst some initiatives have been established in the UK (My Home Life, 2021; Skills for Care, 2021c), more could be done to support leadership in care homes. This is also the case internationally, with data from the United States of America, Canada, Sweden and Australia (Wunderlich and Kohler, 2001; Royal College of Nursing, 2015; Edvardsson, 2016) along with research spanning the last two decades (Havig and Hollister, 2018; Dawes and Topp, 2022) consistently emphasising limited attention to ensure leaders across the globe have the capacity and competence to achieve quality and safety standards (McGilton et al., 2020).

A lack of training for care workers to navigate workplace relationships

The lack of training, supervision and support often extends to the care workforce. This creates challenges for staff to acquire the skills needed to navigate workplace relationships.

Care homes are organisationally isolated from the rest of health and social settings. Staff in the care home sector do not routinely benefit from the equivalent continuing professional development that is available in primary and secondary health-care services. In the UK, the Government acknowledged in October 2020 the disparity between the amount of public money spent on social care training compared to training in the National Health Service (NHS). In a publication exploring issues related to the social care workforce, social care teams reported they wanted to work towards professional qualifications more in line with NHS qualifications (UK Parliament, 2020). Care workers called for more integrated training in line with the teaching care homes pilot run by Care England and the Department of Health and Social Care. However, training and development in social care was described as ‘a career [at] a standstill’, with too few opportunities for training and progression (UK Parliament, 2020).

In this current climate, it is often up to each care home organisation to source and pay for the training that their staff need to work collaboratively.

Many providers, particularly those where the mode of operation is small, struggle to provide staff with the advanced training and skills needed, such as communication and conflict resolution, to work together to care effectively for people with complex needs (Skills for Care, 2018, 2022). Instead, training is largely focused on meeting minimum standards that home managers must apply to meet their statutory obligations and requirements of regulators, the Health and Safety Executive and local authority purchasers (Health and Safety Executive, 2019b; Care Quality Commission, 2022c). Mandatory training areas such as Health and Safety, Fire Safety, Equality, Diversity and Human Rights, Infection, Prevention and Control, Manual Handling, Food Hygiene/Food Safety Awareness and Safeguarding Adults are the most common (BVS Training, 2022).

So what does this mean for co-worker relationships in care homes?

The opportunities

The challenges we have outlined are not exhaustive, but represent opportunities for practice and future research. We suggest supporting leadership at all levels, and promoting communication skills within teams should be emphasised and prioritised if we are to offset the gap created by the absence of HR departments within some organisations. While our suggestions are not new, historically, they have not been the focus of care home research.

Supporting leadership at all levels throughout the care home

The importance of leadership for improving quality is well recognised by regulators (Skills for Care, 2018; Care Quality Commission, 2019), policy makers (UK Parliament, 2020) and research (Havig et al., 2011; Orellana et al., 2017; Poels et al., 2020; Haunch et al., 2021). A recent realist review (Haunch et al., 2021) offers theoretical explanations that co-worker relationships are not only influenced by the care home manager, but also unit-level supervisors (often nurses and senior care workers) who have an integral role in minimising conflict and promoting reciprocity. The synthesis showed that certain behaviours of unit-level leaders fostered reciprocity among teams, including clearly communicating expectations of staff, ways of working and their behaviours, promoting shared goals and mutual respect, helping out on the floor, and openly discussing and resolving problems as a team (Haunch et al., 2021). Experienced staff also have an important leadership role to build confidence with less-experienced/confident staff.

Adaptive leadership postulates that leadership is an emerging property of systems – like care homes – rather than a management role of position of authority. This is because co-worker relationships arise from formal and informal interactions among staff. These interactions are non-linear and dynamic, occurring at all levels of the organisation (Anderson et al., 2003). An adaptive style of leadership distinguishes between technical and adaptive challenges co-workers face on a day-to-day basis. Technical challenges are issues that can be effectively addressed easily, e.g. through additional resources, or a specific expertise or skill, often enacted with a policy or procedure by those in a management role. Adding additional staff during times of sickness is a technical solution. By contrast, adaptive challenges are challenges without a simple solution. They are more difficult to identify and describe and require revising behaviours and attitudes. For example, improving morale in the team cannot be fixed with a policy or procedure (of simply adding staff). Instead, solutions to such problems must be allowed to emerge from the interaction of the people in the organisation who face the challenge. Adaptive leadership thus is composed of a set of strategies and behaviours that are used to facilitate the adaptive work, arising from the individuals in the organisation that allow the adaptive work to occur. It requires recognising and addressing adaptive challenges as well as technical ones (Corazzini et al., 2015).

Much of the research around leadership, however, is descriptive. There is a lack of intervention or experimental studies to test out leadership styles in practice (Poels et al., 2020). Testing the influence of leadership styles, e.g. adaptive leadership, on co-worker relationships would offer important insights for the sector.

The following are calls to action:

• • Practice: Those working in, managing and leading teams should role model behaviours designed to foster reciprocity. Supervision should be less about performance and more about reflection and learning, particularly in relation to how they communicate with their colleagues, i.e. taking away the supervision ethos of ‘are you performing or not’ and change it to ‘let's give you supervision to support and learn’ and action learning sets that encourage staff to work together to solve problems.

• • Research: Experimental research to test the effectiveness of leadership styles, e.g. adaptive leadership, is an important next step to understand and promote co-worker relationships.

• • Policy: Funding needs to be made available for leadership training for staff at all levels. Closer working across health and social care and equal opportunity to access training across this system is an imperative.

Improving the communication skills of individual care workers to promote co-worker relationships

In addition to strengthening the leadership skills of care home staff, we suggest improving the communication skills of care workers will promote collaborative co-worker relationships. Unlike nurses, who gain communication skills through a mix of education (role playing, interactive, experiential teaching strategies) and practice (Lux et al., 2014), communication as a skill is something in which care workers are not routinely trained (Williams et al., 2016; Skills for Care, 2018).

Many care workers, therefore, perform complex work without qualifications and training, making their role challenging (Social Care Institute for Excellence, 2012). Care workers provide 90 per cent of hands-on care. They see residents every day and intuitively know when something is wrong (Laging et al., 2018). Care workers often rely on instinct and their knowledge of residents to detect when something is wrong and report it to their supervisor. They may not be able to articulate what is wrong with residents, other than knowing they are ‘not right’, and may even doubt their own thoughts about this (Winchester, 2003).

As there is often only one nurse or senior care worker on shift, they rely on care workers to be their eyes and ears on the front line. Being able to communicate effectively is imperative (Tingström et al., 2015). The success of information flow is highly influenced by the conversations the care workers have, their ability to listen and check understanding, their use of non-verbal communication skills, understanding cultural differences and how they might impact communication, and understanding how disability and physical and mental conditions might impact communication. Poor communication with their co-workers might mean care workers keep quiet or do not seek help about any concerns they may have. This could have catastrophic consequences for residents (Johansson-Pajala et al., 2016; Ostaszkiewicz et al., 2016; Odberg et al., 2019).

Communication skills are widely recognised within the literature as necessary tools for providing quality care (Kourkouta and Papathanasiou, 2014) and have been suggested to underpin collaborative co-worker relationships (Hofmeyer and Marck, 2008).

Whilst individual variation occurs, communication is perceived to be a skill that develops over time, with experience and support from more experienced staff, in caring environments (Duddle and Boughton, 2007; Kim and Oh, 2016). Those with more experience are often reported to have strong interpersonal skills which help them confidently evaluate social situations and determine what is expected or required to respond appropriately (Hoare et al., 2013). Work experience, in addition to education, is therefore a key predictor of advanced communication skills in care workers (Duddle and Boughton, 2007; Lux et al., 2014; Madden et al., 2017). The notion that people develop communication skills over time fits with the nursing literature (Benner, 2004; Ozdemir, 2019). Benner (2004) introduced the concept that expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experiences.

Skills for Care (2022) estimate that 56 per cent of care workers have less than three years working in their current role, with 11 per cent of care workers being under 25 years old. This highlights the importance of creating environments where care workers can learn communication skills over time in practice. However, since communication skills are a key component of nursing education, it can be argued that care workers should have the opportunity for formal training and development of this skill set, to promote confidence and competence in communication skills.

The following are calls to action:

• • Practice: Managers should encourage their staff to have open and honest conversations. Registered managers could also refer to regulatory documents rated as outstanding (publicly available) to get ideas about what other care home managers do to improve communication skills, e.g. workshops, job swaps, group reflection, all of which improve communication. This will promote environments where care workers can learn communication from their colleagues.

• • Research: Understanding how to implement communication training is important – e.g. tools developed by social care organisations such as Skills for Care (2021b) and academics (Sprangers et al., 2015; Franzmann et al., 2016) – as well as evaluating the benefit for staff and residents.

• • Policy: Ensuring the alignment of social care worker training with training offered across the health system is important and will improve the professional recognition of social care staff. We further recommend that the workforce development fund be expanded to implement the plan, ensuring that all staff are able to access funding for training and career development.

Conclusion

Care home work is challenging and emotionally demanding. Staff work long hours and provide complex care for little reward or recognition. Pay is low and as such the ability of staff to demand more and better is limited. Many staff are less educated than counterparts elsewhere in health and social care and professionalism is less evident, resulting in disempowerment of a workforce who do not always feel valued by society. Consequently, the main support for workers within care homes comes directly from their colleagues and line managers. Collaborative co-worker relationships in these contexts are therefore paramount. An important starting point should be focusing on developing leadership at all levels and providing staff with the advanced communication skills they require to manage their relationships with their colleagues and do their jobs effectively.