Responding to one of the comments on my first blog post, I agree that a key issue is that staff need to feel valued and motivated – staff performance relies on two things – skills and motivation.
Organisations are relatively good at dealing with the skills issue – e.g through training – although sometimes they forget that applying skills is not an inevitable consequence of training. To develop skills, they need to do hands on training and ongoing coaching (and other elements of practice leadership) to help shape up performance on the job.
Do you need to have more qualifications to become more skilled?
It is important to note that being skilled does not necessarily equate to having more qualifications. For good support, the most important thing appears to be the knowledge and skills that are gained from specific training in person-centred approaches that must include a hands on, experiential element. Of course where professional qualifications include that type of training and experience as part of their programmes then we see more skilled staff . I was really encouraged recently to hear that learning disability nurses in Scotland now complete a module in active support as part of their training.
The role of motivation
Coming back to what is needed for successful implementation – motivation is often forgotten by senior managers when trying to improve services. Motivation comes primarily through two routes – values and consequences.
- Values: The values of those supporting people, whether volunteers, front-line staff or managers and the perception staff have of the values of their managers are both equally important. If staff only see the people they support as ill or disabled and therefore primarily needing care or nursing then this can affect their willingness to use approaches that enable and empower. Please note this is not the same as leaving people to their own devices but rather sensitively and positively supporting people towards greater skills and more involvement and generally better quality of life.
If staff see people as
- having at least some skills and abilities and positive attributes,
- as being like themselves,
- deserving of a good quality of life,
- as good company etc.
then they are more likely to work naturally with enabling and empowering approaches.
Managers views matter
However, even if staff have such positive approaches themselves, and have been equipped with the skills, they also need to know that this is the most important thing to their managers.
If staff think that what their managers want is simply to comply with certain standards, ticking boxes rather than focusing on outcomes for the people supported, then that is what staff will focus their efforts on.
If they think that what managers value is making a profit, keeping the house clean and well maintained, or filling in paperwork etc. then that is what they will focus on.
However if they think that managers really care about the quality of life and quality of support they provide to people then they are much more likely to focus on engagement, active support and other person-centred approaches.
If managers visit and ask the right questions (similarly with trustees)and can also pick up good support and even make suggestions for things to try then it can make an enormous difference to staff motivation. Managers must think about messages given to staff by the mission statement, job descriptions, other polices and procedures such as health and safety, the website, recruitment processes, quality assurance or auditing processes, etc.
Another important element here is external context – such as the demands staff and managers perceive as coming from the Care Quality Commission. If services get a good or excellent rating for having all the paperwork completed and inspectors don’t pick up on the fact that service users are sitting around doing nothing while staff are busy filling in the paperwork or cleaning (or in the case of Winterbourne View, also doing nothing) then that is the wrong message.
If those services where staff are so busy enabling people that some of the paperwork isn’t completed get their knuckles rapped then then that creates a disincentive for active support.
Does how we inspect services matter?
However if inspectors come in and the first thing they do is sit and watch for a bit, talk to people, but essentially observe what is happening, how staff are supporting people and then if necessary go to check out the supportive documentation in the office, this creates a completely different motivational context for staff. This is especially the case if they mention in their reports and commend services for high levels of engagement and good quality of support in terms of active support, communication, autism-friendly practices and positive behaviour support. If inspectors know what good support and good outcomes look like and are trained to observe and comment on these, then organisations will be encouraged to focus on the quality of the support staff provide and be able to demonstrate the outcomes in terms of the quality of life of the people they support.
I firmly believe that things are about to change for the better in terms of inspection and registration processes. If inspectors are going to be looking for implementation of positive behaviour support and in particular whether people are being enabled and supported to spend their time engaged in meaningful activities and relationships then this will have a powerful effect on the motivational context in which services operate. A number of things are needed to make this happen including training for inspectors. Of course the focus on engagement and active support and other person-centred approaches to support has to be on all services – registered care homes and domiciliary care. If we shape up the quality of our services in general then the chances are that fewer and fewer people will need to access assessment and treatment units and even if they do, their stay will really be for assessment and treatment because there will be high quality community based options for them to move on to.
What about views of commissioners?
Commissioners also are key in the motivational context for organisations to provide good support. Commissioners have to know what good looks like and must commission services that are good. The results from our recent study funded by the School of Social Care Research, found that providing high quality support that improved outcomes of people – primarily active support but where active support was high then support for communication, autism friendly practices and positive behaviour support were also better implemented – did not require significantly more staff and thus was not more expensive than providing much weaker inconsistent support where outcomes were poorer. This is because good support is about how staff work, what they do when they are with people, not about how many staff (obviously once a basic threshold is reached) are employed or how qualified they are in a traditional sense. Staff with the right values, the right training and the right support to enable people is what is most important. Commissioners also have to take a long term view (difficult i know given the financial constraints and the constant restructuring of health and social care systems and processes) but sometimes a little investment now can save a lot of money in the future. At the very least they need to ensuring that the services they do commission are providing the outcomes for people that they should be, in line with the Care Act.
2. Consequences: As well as values and expectations, the other aspect that is involved in creating a positive motivational context for staff to work in, is that the consequences have to be clear, consistent and transparent. Obviously consequences can come from management and here there has to be as strong a process to recognise and reward good practice as there is to deal with poor practice, which does have to be dealt with. It is not sufficient to just focus on the good stuff. To shape up quality over time, staff need to be supported to improve their practices. I worked with an organisation once where the rule was that managers had to give 4 pieces of positive feedback before they were allowed to give “negative” feedback — nothing ever got better. Of course how you deal with poorer practice doesn’t have to feel negative. In fact the process of improving practice should be so much part of the service culture that staff see it as a positive thing. If it is done in a positive, collaborative, reflective way then this is by far the most effective method.
How can we support managers?
However this leads us to another issue in that many front line managers have not had the training or experience of working to lead practices in this way in the past. This is something that should be a critical part of any training for managers working in social care settings. I am pleased to see that Skills for Care are starting to think about the issue of active support in terms of front-line staff competencies. Leading active support and other person-centred approaches needs to feature to be key management competencies too.
Other members of the staff team provide important consequences too. If there is a supportive staff culture with a shared vision and where staff all value person-centred approaches then implementation will be much easier. However if there are members of the team who do not work in this way and they show disapproval when other staff do, then this can have a negative effect on the motivation of staff.
What are the consequences of good support?
Consequences also come from the people being supported. If staff support people well there will be positive consequences from the people they support – a smile, a laugh or simply just seeing someone do something they have never done before or hearing someone say “i never knew he could do that”. Remember that if people choose to get engaged they are telling us that we have done something right in terms of support – we have presented the task well so that they have understood and we have a history of providing them with enough of the right type of help to ensure success. Of course if we provide poor or inconsistent support for people, then they also provide consequences – either in the form of withdrawal or in challenging behaviour.
Person centred support 
I fully support the concepts above but would like to add another.
It may be that one of the ways to consider the issue of supporting staff is to help them to think about what their role is on a daily basis. I suspect if asked most would say to care for the individuals in the service.However if you look at the definition of ‘care’ is it what we would really want them to be doing? Here is one I found:-
‘provision of what is necessary for the health, welfare, maintenance and protection of someone or something’ Google . To me the definition indicates doing something to someone, not with them , not respecting them.
If we change the term of everyone within an organisation into that of ‘coach’ it is clear that the focus shifts. A definition I found for this role reflects much more what we would hope to see:
‘Coaching is about enabling individuals to make conscious decisions and empowering them to become leaders in their own lives’ (Wise 2010)
The role of a coach is empowering , it is about providing that support to assist in helping the people in the service to develop and make positive decisions. That will be true not only for the service users but for everyone, from management to the staff ‘coaching’ the residents. It may seem a little change of title but it can lead to a positive shift in culture.
Thanks Barbara – you are quite right – coaching is an important part of the role of the practice leader and is critical for shaping up skills. We will post a more detailed post on the role of front line managers and the importance of practice leadership later.
Having worked both inside and outside the UK a major flaw I see in the UK’s provision, is pay and the professionalism of those who provide direct care. How can you expect quality care when those charged with the direct provision of that care are paid less than they would earn in a supermarket?
By not paying direct support staff a living wage, services make it economical impossible for those employed, to sustain relationships with those they support. A parent once illustrated this to me by remarking ‘anyone who is any good here is gone after a couple of months’.
If those responsible for direct care where professionally trained and paid a salary congruent with the responsibility entailed in the position (similar to that of a teacher, police officer or nurse). People who have a genuine talent and love for the job could choose it as a career. Rather than choosing it as a brief stepping stone to something else.
Leadership, clinical support, oversight and governance all continue to be of critical importance, but I believe you can’t build these things on a foundation that is inherently unstable.
Thank you for your comment Alan, I absolutely agree that staff must be valued and in the UK they are poorly paid and not valued in general for the work they do. However there is no evidence that these factors make a difference to the quality of the support staff provide (although would probably help the motivation). In many countries people working in institutions as well as community based settings do have high level qualifications and are well paid but this does not result in good practices. Whereas, in Croatia I have seen people receive a really good basic training in person-centred support (and have decent leadership) and then provide great active support in situations where they are supporting 4 people with mixed levels of need despite only being paid €50 euros a week. I am not saying that staff shouldn’t be paid more and have relevant qualifications providing those qualifications focus on the right information. But person-centred support needs staff with the right values first and foremost – the skills can be provided. The key thing is that supporting people with learning disabilities needs to be seen as a valued profession. More money for staff would be wonderful but resources are limited and if we push for very high salaries and qualifications we risk returning to a more institutionalised and medical model as such high levels of pay are likely to be unsustainable in community based settings. Look at Ireland – a major barrier in the deinstitutionalisation process had been the fact that pay for all staff in institutions was raised to a much higher level which could be sustained when lower staffing ratios were “possible” due to congregate settings but was not financially sustainable when in smaller congregate settings. So I absolutely agree that staff need to have the work they do valued, recognised and appropriately remunerated but this is only one part of a multi-faceted context and higher pay and qualifications do not on their own ensure good practice in terms of supporting people. We have to be a little careful to get the balance of incentives correct.