How do we provide better mental health support for care home staff?

Previous research has highlighted the risk factors associated with high stress amongst care home staff, including high staff turnover and absenteeism* and staff malpractice**. However, the fragmentation of care home provision, both in terms of different types and sizes of providers of services and the complex process of commissioning/purchasing services, poses significant challenges to ensuring consistent support for staff in care homes.

We spoke to those 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 spoke to stakeholders representing various agencies and organisations that support the sector to find out what could be done to improve the emotional well-being of this vital workforce.

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 of the managers we interviewed described unmanageable workloads consisting of a myriad of organisational demands that often led to working well-above contracted hours. Several managers described being on call and available 24/7, including during periods of leave. Some described feeling that you constantly have to ‘cover’ yourself and make sure that you are prepared for upcoming checks. Many of the 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 staff 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 that they had continued to present at work to role model that it was safe to do so and would fill in gaps that absent staff would otherwise attend to, such as cleaning and shopping. Some continued to work remotely while isolating with symptoms to feel that 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.

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 that their role, often complex and comprising aspects such as enabling residents and upholding their human rights, was overlooked, and under-appreciated by the public, especially when compared to 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 (BAME) and told us that they and their families felt at particular risk). There were also challenges in managing the stress, confusion, and fear of residents (themselves experiencing a lack of stimulation and restrictions of peri pandemic care), who often could not grasp why restrictions were being imposed on them.

Neither the RCMs or frontline staff we spoke to felt that there was adequate support to help them cope with the highly emotive material and pressures they are frequently subjected to, both on a day-to-day basis and during the pandemic. The majority of those we spoke to felt that that the culture in the sector 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’ for staff, this was not always understood by their staff. We heard that some staff did not feel supported, respected, or cared for by the management team and/or organisation, especially during the pandemic. One staff member felt that 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.

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 of the health and social care commissioners described a disconnect not only within the care home sector, but also between health and social care. A social care commissioner we interviewed spoke of a tension of cultures and a “clash of different worlds” between the two sectors due to differing ethos in the provision of care. Some spoke of the level of investment in staff training and development in the health sector and told us that “far less” is invested in the care workforce. One of the commissioners 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 that 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 that 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 co-production 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.

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 relationship with RCMs and ensure that 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.

What next?

1. Keeping Well online portal (https://www.keepingwellnwl.nhs.uk/). 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.

2. Online community platform. Recent studies have shown the importance of social bonds in acting as protective factors during times of great stress (Elahi et al. 2018; Greenberg & Tracy, 2020). We need to build on this evidence of ‘what works’. Staff groups currently use social media (e.g. WhatsApp) 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.

3. RCMs and their staff need regular 1:1 well-being conversations that specifically asks them how they feel, encourages them to reflect on their emotional well-being, as well as their practice and encourages change as a result.

4. Staff need team wellbeing meetings to explore common issues, increase awareness and normalise the conversation around wellbeing at work.

5. Buddying systems can enable staff to support each other through the challenges of their work.

6. Develop career progression and opportunities across health and social care and to build shared understanding.