Research shows that the attitudes of nursing home staff towards residents are influenced by their personal value frameworks and that this can create circumstances more likely to produce abuse
Earlier this year, Nursing Times published data on the extent and nature of residents’ abuse in private-sector nursing homes, followed by outcomes showing that this abuse is not always reported – and is sometimes deliberately concealed. These findings come from an empirical mixed-method study recently conducted in nursing homes in four local authority areas in England. This third article presents further findings from the same research, this time focusing on staff’s personal value frameworks and how these influence their attitudes and behaviours. One of the lessons to be learned is that nursing homes need to tighten their recruitment processes and supervision strategies to ensure that staff have values and show behaviours that are compatible with a caring role.
Citation: Moore S (2017) Influence of personal values on nursing home staff’s attitudes to care. Nursing Times [online]; 113: 8, 37-40.
Author: Steve Moore is commissioner of care and nursing home services, Dudley Metropolitan Borough Council.
Staff employed to care for residents in nursing homes bring their own value frameworks with them, but these value frameworks are not necessarily congruent with the principles of good care and desirable personal attributes. Two articles published in Nursing Times earlier this year described findings from a mixed-method study showing that older people in private-sector nursing homes continue to experience abuse (Moore, 2017a) and that this abuse is not always appropriately reported (Moore, 2017b). This third article presents findings from the same research, obtained via semi-structured interviews conducted in 12 nursing homes, which demonstrate that the personal value frameworks of staff are an important factor explaining the occurrence of abuse.
Much of the literature exploring personal values is concerned with what people value in their lives, and to what they aspire to achieve this – in other words, ‘end’ (terminal) and ‘means’ (instrumental) values (Rokeach, 1973). These could be, for example, self-direction and stimulation (instrumental values) or power (a terminal value) (Schwartz and Rubel 2006; Schwartz et al, 2001). These instrumental and terminal values are also treated in terms of how they are positively valued, and exclude consideration of whether they are actively evaluated in negative terms (Schwartz and Rubel, 2005).
However, personal value judgements do not only depend on individuals’ beliefs about what and who is good, valuable and worthwhile, but also on their beliefs about what and who is bad, undesirable and worthless. Value judgements are founded in part on individuals’ beliefs about the societal and personal consequences arising from the people about whom the judgements are being made, either as individuals or as groups. So, for example, older people, who no longer work and pay taxes and national insurance and require expensive care, thereby increasing the tax burden placed upon those who do pay taxes, may be viewed as a burden upon society and not an asset to it (Santrock, 2007). According to Bruun (2007) “a person who is living is, by definition, value-oriented in the sense that they are constantly judging and evaluating their surrounding world”. Beliefs and subsequent value judgements thereby affect the perceived worth or benefits derived from interpersonal relations with the people about whom the judgements are being made.
The combination of non-evaluative beliefs and positive or negative evaluations derived from these beliefs form attitudes (Mansell et al, 2007; Fitzsimmons and Barr, 1997), which give rise to a predisposition to think and behave in certain ways in response to certain stimuli (Bowers et al, 2009; Jimenez, 2009; Fitzsimmons and Barr, 1997).
Individuals who come to value older people positively are likely to develop a positive, non-prejudicial affective attitude towards them. Conversely, if older people are valued negatively, a negative, prejudicial affective attitude may arise. This affective component influences subsequent behaviours, and value orientation affects human action (Schwartz, 1992).
Value judgement frameworks are formed during childhood, adolescence and maturation to adulthood through socialisation. Young people go through a period of socialisation around the ages of 14–21, where relational interactivity and social values are consolidated from earlier ‘imprinting’ and ‘modelling’ periods; these values remain largely unchanged thereafter, except as a consequence of significant personal trauma (Massey, 1979).
Verplanken and Holland (2002) described the resilience of adults’ consolidated value systems, attributing this to the importance of value formation in the conception of self. As a consequence, negative value judgements and potential prejudicial attitudes towards older people among nursing home staff cannot be eliminated simply by declaring that all staff should adopt better value frameworks.
Between 2011 and 2015, I conducted semi-structured, face-to-face interviews in 12 private nursing homes in four local authority areas in England. The other method employed for this research was an anonymous questionnaire completed by staff in five other nursing homes. I interviewed 12 nursing home owners (two of whom had previously been registered nurses), 12 nursing home managers (10 of whom were registered nurses) and 12 nurses or care staff. The definition and typology of abuse used in the explanatory notes were those used in the No Secrets guidance (Department of Health, 2000).
The questions were designed to encourage nurses and care staff to express how they experienced and perceived their social world and its influence on them as people who are paid to care for others. As a consequence, interviews could depart from the set question schedule – indeed this was perceived as a good thing, as it would help explore experiences and perceptions not considered at questionnaire design stage. The interview itself was potentially a site of knowledge construction (Hand, 2003).
I avoided leading questions, preferring open ones that would generate responses formulated in large part by the interviewees themselves (Denscombe, 2010), which would draw out their experiences and interpretations (Holstein and Gubrium, 2004). Participants would, therefore, direct the course of the interview, potentially moving into unanticipated areas of interest. The idea was that this would increase the depth of collected data (Denzin and Lincoln, 2000) and open the door to the disclosure of unexpected information about staff’s personal value frameworks.
Views of owners and managers
Owners, managers and staff all recognised that, in the nursing homes where they worked, professionals employed in caring roles did not always value residents positively, and sometimes abused them as a result. Some owners and managers said that many staff, whether nurses or care workers, did not treat residents with respect or dignity and that some could behave in a manner that suggested they did not believe residents should have a voice in their care. One manager said:
“A lot of people come for care jobs and they don’t see older people [as] deserving of respect and dignity. It’s not about staff numbers, it’s [about] the right staff who care, with the right values to make a difference.”
Some managers talked specifically about the values held by staff and their consequent attitudes towards older people in their care. One said, for example:
“Staff giving care must have the right attitude […] to actually want to do something for that person, and sometimes it’s smelly and dirty what you have to do. Sometimes it’s an unpleasant and difficult job, and you’ve got to think that person is actually worth something […] You can’t change people’s values. It doesn’t matter whether they are nurses or [whether] they’ve got NVQ 2 or 3 or dementia training, it comes down to attitude and values. And if they haven’t got that, you can do whatever training you like but it won’t make a jot of difference.”
This statement was typical of many others indicating that there may be a link between how staff value residents, whether they have an appropriate attitude to care, and how likely they are to perpetrate abuse.
Views of nurses and care staff
Staff’s values and attitudes being in conflict with caring for older people was a recurrent theme among owners and managers. However, nurses and care staff also recognised that the values held by their colleagues were sometimes incompatible with the job. One care staff member said:
“Carers also have that problem making the connection with older people, you’ve got to have that caring nature to make a connection. I stand and watch and listen, and they don’t speak to the old people, ask them how they are, did they enjoy their breakfast… It’s like they aren’t worthy of communication.”
Again, this response mentions the perception of the older person’s ‘worth’. Staff expressed the view that some of their colleagues appeared not to care about, or value, the people they were employed to look after and had little interest in them as individuals. This is an attitude often linked with perceptions of poor cognitive ability or short prognosis. For example, one nurse, explained that:
“Well, in truth, most of these old people don’t know what’s going on anyway. So they don’t know whether they are clean or not, do they?”.
Another nurse explained:
“Some of us see it all as a bit futile really so they don’t bother. Futile because they [the residents] are going to die soon.”
These are examples of value judgements made by staff about the older people they are caring for and their perceived worth. Such negative value judgements have, in turn, a negative influence on staff’s attitudes and subsequent actions. This may explain in part the often cruel and sometimes premeditated abuse found to be occurring in nursing homes today (Moore, 2017a).
The value judgement component
Our understanding of how staff’s value judgements and attitudes may lead to abuse of nursing home residents can be enhanced by considering three components of age-related prejudice applicable at both individual and societal level – cognitive, affective and behavioural (Baron and Byrne, 2002).
This research adds a fourth component – ‘value judgement’ – situated between the ‘cognitive’ and ‘affective’ ones (Box 1). Value judgements formed by individuals generate either positive or negative affects (the word ‘affect’ is used here in the sense of feeling, emotion or mood associated with an idea or action), and these affects give rise to attitudes that may, in turn, produce abusive behaviour.
Box 1. Components of age-related prejudice
- Cognitive: beliefs and stereotypes about older people
- Value judgement: conclusions made about older people
- Affective: prejudicial attitudes towards older people
- Behavioural: direct and indirect discriminatory practices towards older people
Source: Adapted from Baron and Byrne (2002)
However, it must be noted that it was not possible to demonstrate, from this research, a direct causal link between negative value judgements and abuse. Negative value judgements about older people do not necessarily mean that individuals holding these judgements will engage, or will always engage, in abusive behaviours.
Flaws of the policy-led approach
When looking at government policy and supporting research, it quickly becomes apparent that positive ‘values’ are considered crucial in the fight against abuse Policy is replete with calls for care providers to hold appropriate ‘values’ (Killett et al, 2013), such as respect for those in their care. However, the reasoning behind a policy-led approach to modifying behaviours at the micro-level of an individual nursing home has two fundamental flaws.
First, policy often confuses value judgements with principles of care: it mentions ‘values’ that are not values in the sense of judging the worth, usefulness, desirability or merit of someone or something (which is what the verb ‘to value’ means), but desired principles of good practice (as in ‘value’ as a noun). For example, the ‘values’ of ‘courage’ and ‘imagination’ have been described as desirable among staff (Skills for Care, 2013), but these are personal attributes that may be applied to acts of caring, not value judgements of the people who require care.
Second, in any case, individual staff members apply their own evaluative judgement process to any organisational principle or personal attribute and, crucially, to the people these principles or attributes are supposed to protect. Although this evaluative process will be influenced by many factors – such as upbringing, personal relationships, education and the wider society – the judgement remains formed and exercised by the individual nursing or care staff member. Consequently, staff will also decide whether or not to adhere to the recommended care principles, and adopt the desirable personal attributes.
Testing staff’s aptitude for caring
Some researchers have raised the question of staff’s aptitude or suitability for caring for family and domiciliary care provision (Froggat et al, 2009) but this has been treated briefly and without much explanation.
Only recently has government policy tentatively recognised the importance of ‘testing values, and aptitude [of potential staff] at the recruitment stage’: this was in the 2013 review into healthcare assistants and support workers in the NHS and social care settings (Cavendish, 2013). Unfortunately, the review only mentions value-oriented recruitment once and offers no guidance as to how it might be achieved. Furthermore, what is presented as ‘values’ is again better described as ‘principles of care’. The report fails to conceptualise that it is individuals who subsequently confer value judgements on these principles.
Weak recruitment processes, and the fact that some people apply to nursing homes simply because they need a job, compound the difficulty of determining the motivations and true value judgements of prospective staff during interviews.
Values versus desirable principles
Killett et al (2013) acknowledge the importance of ensuring that the ‘values demonstrated in practice’ by nursing homes match the values these homes claim to possess. However, these authors refer to values put forward by organisations rather than value judgements made by staff; they use the term ‘values’ as synonymous with care principles and personal attributes, for example citing ‘leading by example’ as a value. They assume that all staff will readily adopt organisational values, which may not be the case (Jimenez, 2009) and also fail to acknowledge that staff will inevitably make value judgements.
As Schein (2004) explains about organisational cultures in general, “values are open to discussion and people can agree to disagree about them”. In the context of the NHS, this is perhaps reflected in the “gulf between the principles and values of the NHS Constitution and the felt reality of being an older person in the care of the NHS” highlighted by the Parliamentary and Health Service Ombudsman (2011).
In other words, the values of staff directly providing care may not be congruent with desired organisational values.
Values cannot be forced onto people
It cannot be assumed that people who enter the nursing home workforce have developed value judgements that are compatible with the demands of caring for older people – who often require extensive support and have cognitive difficulties that make them particularly dependent on staff. In the interviews, many study participants acknowledged the incompatibility of the value judgements held by some of their peers with the work they are employed to do, challenging the widespread assumption that nurses and care staff always value people in their care positively. Fundamentally, value judgement frameworks compatible with the job of providing care to vulnerable people cannot be forced upon staff.
This empirical research shows that the personal value frameworks of nursing and care staff working in private-sector nursing homes is an important factor in the creation of circumstances in which abuse of older people may occur. The failure of government policy and research to accurately define what is meant by ‘values’ compounds the lack of attention given to staff’s aptitude for caring, leading to some staff abusing residents who they value negatively in their own personal world views. Remedial measures that nurses managing nursing homes can take (Box 2) include trying to ascertain candidates’ personal value frameworks when recruiting staff, and monitoring the adequacy of staff’s behaviours through robust supervision.
Box 2. Recommendations for nurses managing nursing homes
- At recruitment stage, use thorough assessment methods to determine candidates’ true personal value frameworks
- Through robust supervision processes, ensure that the personal value frameworks nursing and care staff claim to have are in harmony with their behaviours when looking after residents
- For comprehensive supervision, use a mix of practice observation, unannounced spot audits (including out of hours) and 360-degree feedback (a staff appraisal system that seeks feedback from peers and subordinates)
- Regularly seek feedback from residents and their families
- If abuse occurs, apply root cause analysis to explore any indicators of personal values as causal factors (in root cause analysis, a factor is considered causal if its removal prevents the problem from recurring)
- People’s personal value judgement frameworks are formed during childhood and adolescence, and remain largely unchanged thereafter
- If a person has come to view older people negatively, they are likely to develop a negative, prejudicial affective attitude towards them
- There may be a link between how nursing home staff value residents and how likely they are to perpetrate abuse
- People working in nursing homes cannot be assumed to have personal value judgements compatible with the demands of caring for older people
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