Paid carers: a new research challenge

Paid carers play a key role in the front line of care, particularly in the Cinderella specialisms; mental health and older people's services. This workforce is growing rapidly in many countries, driven by increasing numbers of frail older people many of whom have dementia, who are in need of practical support, and the pressure to save money which incentivises the substitution of lower paid carers for higher paid professionals such as nurses. This workforce who provide direct care are likely to be called healthcare (or care) assistants, health and social care support workers, certified nursing assistants, nurse's aides or auxiliaries. While there is a National Association of Health Care Assistants in the United States, with 26,000 members drawn from nursing home employees, such representative associations are unusual. These largely unorganised paid carers are the people employed in health and social care who most often deal directly with the recipients. Their ministrations, their emotional intelligence and their capacity to respond to people's needs determine the quality of that care. Yet, they receive less research attention than is warranted by the impact which they evidently have on the patient or resident experience.

With minimal qualifications, paid carers are a flexible workforce, predominantly female, on low wage levels, many working part-time to fit in with family responsibilities, and accepting of the emotional rewards of the job rather than seeking career advancement (Department of Health, 2013; Schneider, Scales, Bailey, & Lloyd, 2010). They typically support patients in hospital or residents in care homes in activities of daily living (Thornley, 2000). In hospital, they are, in principle, working to nurses’ instructions (Hasson, McKenna, & Keeney, 2013), although in community services they may have greater autonomy (Daykin & Clarke, 2000). In the United Kingdom, student nurses have largely been replaced on wards by this new workforce (Chang & Lam, 1998). Health care assistants (HCAs) tend to spend more time with patients than even the registered nurses, who are frequently occupied in administrative duties (Daykin & Clarke, 2000; Spilsbury & Meyer, 2004). Perhaps this is why patients sometimes find HCAs more approachable than nurses (Kessler, Heron, Dopson, Magee, & Swain, 2010).

Numbers of paid carers in health and social care have risen in the United Kingdom to over 1.5 m, compared to fewer than half a million nurses, and – especially since the revelations of abuse at Winterbourne View (Bubb, 2014) and the Mid-Staffs Enquiry (Francis, 2013) -- more attention has been given to this workforce from government quarters. The Cavendish Review (Department of Health, 2013) supported regulation of the profession through registration and the introduction of the Care Certificate as required training for new recruits. However, with annual staff turnover of between 14% (National Health Service) and 20% (social care), it will take many years for the Care Certificate to percolate through the workforce, and it may never reach those paid carers who are resistant to change but who have decades of working life ahead of them.

In any country, the costs associated with workforce training may present an obstacle. In addition, from a cynical perspective, access to a pool of unregulated staff whose skills are undervalued in the market offers employers a lot of flexibility. Moreover, once paid carers have certificates which they can transfer from one employer to another, they may become more visible and assertive as a workforce, prepared to defend in public the standards of care to which they aspire (Johnson, 2015). Despite these issues, in the United Kingdom at least, a slow process seems to be under way which aims to transform paid carers into a recognisable, organised and accountable workforce with mandatory training, a recognised qualification and an emerging career path. It is argued that better utilisation of support worker skills can bring about improvements in care: create better career pathways, analyse what functions can be performed by support workers, develop their skills and increase efficiency (Kessler, Heron, & Dopson, 2012).

Research to date has looked mainly at comparisons between registered nurses and HCAs (Chang & Lam, 1998; Keeney, Hasson, McKenna, & Gillen, 2005; Pearcey, 2008; Workman, 1996) between student nurses and HCAs (Wakefield, 2000) or it has concentrated on describing HCA roles using case study approaches (Daykin & Clarke, 2000; James, Butler-Williams, Hunt, & Cox, 2010; Kessler et al., 2010; Spilsbury & Meyer, 2004). There is a need for more high quality research to generate knowledge to inform future development of the paid carer workforce, in order to maximise the benefits for patients and service users. We need comprehensive and reliable baseline information about the paid carer workforce, what experience or training they have, what supervision they receive, their working terms and conditions and their job content. The milestone Cavendish Review was conducted in four months – insufficient time even to count their numbers, and so relies largely on secondary analysis of statistics and qualitative interview and focus group data. The UK National Minimum Dataset for Social Care is an excellent primary source – but it only covers people working in ‘social care’ settings. Longitudinal data which pertain to the entire paid carer workforce is needed. Just as the nursing workforce is surveyed periodically (Buchan, 2013), so paid carers in both health and social care need to be followed throughout their careers to understand how these evolve and respond to the changing context within which they work.

Given the detailed information about the paid carer population from representative survey data, further research questions of importance to the quality of care present themselves. For instance, what are the implications of working at the front line of care for these individuals themselves for supervision and in-service training? Does care work have physical or psychological effects on staff – and if so, how does that affect patients or service users? Paid carers work in an arena of mental illness, degeneration, bodily emissions and death but they do not share the high social status of nurses or doctors. The status accorded to paid carers is more akin to that given to people who do society's dirty work; rubbish collectors, exterminators and sewage workers (Hughes, 1962). Although this stigma by association might be expected to harm their self-regard, there is some evidence that they tend to unite to resist negative connotations of the work and reinforce its importance, creating strong team identity (Lloyd, Schneider, Scales, Bailey, & Jones, 2011) and asserting moral superiority (Van Dongen, 2001). The issues which arise could be tackled by research into what organisational factors are effective in moderating the negative impacts of paid care, what support systems are effective, and at what cost.

Much of carers’ work involves emotional labour – they are paid to smile and be cheerful, encouraging their charges likewise to align their emotions with the aspirations of the organisation (Bailey, 2015; Johnson, 2015). This introduces problematic ambiguity to the role; for instance, how carers reconcile conflicting demands, such as the ‘performance’ aspect of the job, with the virtue of honesty (Janes, Sidani, Cott, & Rappolt, 2008). It raises questions about employers’ responsibilities to equip and support people who do emotional labour, just as they might be expected to provide tools and occupational health to people doing physical labour. Research should investigate how organisations can recruit people who have the personal qualities and resilience to meet the demands of caring – are they born with the ability or can it be learnt? Is this a job that can be done by anyone or are some better suited than others? Paid carers embody societal attitudes towards frail and dependent members, so society at large also has an interest in this field of enquiry. Can care truly be bought?

With a few important exceptions, race, ethnicity and class have been largely ignored in the research on paid carers, yet the workforce is disproportionately non-white and working class, with a growing proportion of immigrant workers (Hussein et al., 2011). Gender is another burning issue. How many paid carers are simultaneously fulfilling female role stereotypes by caring for their own relatives? Are male and female workers paid the same, promoted and trained on equal terms? Theoretically informed research is called for to explore the impact of gender, class and race on the caring relationship. Sandberg, for example highlights the importance of attending to the prior learning of healthcare assistants, recognising what they bring with them to the job (Sandberg, 2010). In the same way, the influences of ethnicity and enculturation need to be explored, since care work is typical entry job for recent immigrants. With more knowledge about paid carers from a national survey, it would be possible to investigate how demographic variables interact with the other features of the workforce.

Although practice may often digress, the norms of contemporary health and social care practice reject a task-centred understanding of the care process in favour of a focus on the caring relationship (Nolan, Davies, Brown, Keady, & Nolan, 2004; Wasserman & McNamee, 2010). We, therefore, need to know more about all the parties to that relationship, including paid carers; who they are, what their capabilities are, how they see the work and how the rest of the world regards them. The effects of training, supervision and workplace environment are also of critical importance, yet these factors are rarely studied – and hardly ever investigated in relation to client outcomes. Theoretical perspectives from the social sciences, including organisational science and sociology, may help to understand these aspects more deeply so that employers, paid carers and the recipients of care can work towards a more satisfying and effective partnership. As illustrated by the examples given here, concepts such as stigma, dirty work, emotional labour, gender, class, race, ethnicity and power offer useful perspectives on the workforce. Paid carers therefore present a new and varied challenge for researchers in aging and mental health, not forgetting that the purpose of advancing knowledge in this field is ultimately to improve outcomes for the cared-for individuals.