What works is what matters: An ethnographic study of how care workers in care homes learn to care for people living with dementia

The core work of care homes for older people in the UK is increasingly dominated by dementia care. This trend is likely to continue as residential care is often the only option available to meet the needs of many people living with dementia, particularly in the later stages of the condition as a person requires 24-hour care. The day-to-day support provided in residential care is primarily delivered by non-professionally qualified staff, with in-work, competency-based training the key means of developing skills. Current policy, guidance and regulation emphasises the importance of formal training for care workers to improve the quality of care for people living with dementia in care homes. Care home organisations make decisions based on this guidance, and research primarily focusses on the effectiveness of that training and education.

Whilst there is evidence that training positively impacts on care practice and quality in some circumstances, broader understandings and investigations of workplace learning indicate that learning to work is not predominantly a formal experience shaped through training, but is instead characterised by informal opportunities linked to everyday events, interactions, and problem- solving in the workplace. These other factors are highly influential in determining the practices workers learn when engaged in their day-to-day work. However, there has been only limited research addressing this alternative view of learning within care work generally, or from the perspectives of care workers in the context of care homes and the needs of people living with dementia. Without an understanding of ‘learning to care' that includes the perspectives of those who live and work in the care home, and accounts for the impact of the care home context, there is a risk that attention and resources will be focussed on measures that may have only modest impact on the quality of care-giving.

This thesis addresses this gap by answering the question: how do care workers in care homes learn to care for people living with dementia? The study used focussed and critical ethnography to explore the landscape of learning to care within two care homes. Over a period of 14 months the researcher spent 1-2 days per week engaged in fieldwork. Overall, this produced 45 hours of ethnographic observation (encompassing weekdays, weekends and overnight shifts), 18 hours of observations using a focussed dementia-specific observation tool, and semi-structured interviews with 15 staff members, including 9 care workers. Data were analysed thematically both by hand and using NVivo 11 computer software.

The findings from this study showed that care workers experience a multi-level learning process, encompassing three key themes. At the micro-level, workers learn during the day-to-day conduct of their work through a mechanism labelled “what works is what matters” in which they apply, reinforce or reject learning based on whether it is of use in successfully resolving the situations they encounter. Employed within this micro-level process are three components representing the skills, knowledge and experience available to workers: personal resources, resident influences and cultural knowledge. Cultural knowledge consists of macro-level influences generated primarily from a worker’s “interactions with colleagues” and secondarily their “training”. Significantly, this interaction between the micro and macro level enables the organisational culture of the particular care home to strongly influence the care practice learned by workers. Furthermore, this process shows that informal means of learning predominate within the care home, often acting as a mediator on the impact of formalised training and instruction. In particular, the flexible, interpretive and relational work required by person-centred approaches to people living with dementia specifically emphasise these informal means.

Following description and discussion of these findings in relation to prevailing theoretical and empirical understandings of person-centred dementia care, recommendations are made for how to reconceptualise approaches to care worker learning in light of the study’s discoveries. A Learning to Care System that maximises the opportunities provided by specified informal learning methods and responds to the influence of care home culture on learning will be better placed to enhance the quality of care practice and the care experiences of people living with dementia in care homes.