Dimensión Psicológica

Because long-term care often includes personal care elements which are not funded by the NHS, residents undergo means-testing of their assets and income to determine whether they are required to contribute to the cost of their care, and if so, what sum they must pay. As a result of this system, different residents have different funding arrangements, so that while some do not contribute to care costs at all, others wholly fund their own care. In addition, many NuHs accommodate a mix of self-funding and social service funded residents. Participants indicated that a number of consequences regarding residents’ expectations of care, result from the funding system. For example, participants suggested that there is a disparity between the expectations of self-funding residents and those of healthcare professionals regarding what constitutes quality care. Participants stated that quality assessments should be based on the standard of care delivered. However, participants indicated that while potential residents and families take this into consideration, they look for more tangible, material niceties such as superior décor, pleasant views, and modern facilities:

Beth (2): They want different care. They want, not better care, but they want it there and then, and they want a 42 inch plasma screen on the wall, kind of thing.

Bella (3): Like these days, erm, I think the competition is how nice is the home, like you know, the environment, the state-of-the-art, you know, and as you can see, we haven’t got that here [looks around the room and gestures with hands to demonstrate]. We have the care. It’s how people are being looked after.

Participants also suggested that self-funding residents and their families are concerned with staff availability and attentiveness:

Andrea (2): Actually there were patients who, if they don’t get attention straight away would say, they’d be shouting and say, ‘I’ve paid for you, I’m paying for you’. And then some relatives who would come in, you can see and you can feel that, ‘My mum needs attention now. This is what we pay. We pay a lot’.

Elaine (2): They expect better quality of care, so they want you in the room 24/7 sometimes. We’ve had a few people who are privately funded and they have been like that. They expect you there all the time. And you get, ‘I’m paying for this’.

Here Andrea and Elaine proposed that private-funding not only influences residents’ expectations, but that these expectations have an impact on the nurse/resident relationship. Some participants reported that, due to different expectations, self-funding residents can be more demanding and develop a supercilious attitude towards staff:

Beth (2): Because they’re kind of like a customer. (I mean, you can imagine in a shop or whatever) and they always have ‘the- customer-is-always-right’ motif.

Cath (2): And then you get residents that treat you as a servant...So a lot of the barriers about that is from the residents, and what they perceive they should expect for their money.

Difficulties in relationships appear to stem from two causes. Firstly, some participants attributed relationship difficulties to residents’ disclosure regarding funding. As discussed earlier, residents undergo means-testing of their assets and income to determine whether, and what, they are required to contribute to the cost of their care. Although funding details are confidential, Anne explained that some residents choose to divulge details of their funding arrangements to staff and other residents. To comply with the requirements of ethical practice, the participants stressed the importance of treating all residents with equal consideration, regardless of funding arrangements. However, they suggested that this can lead self-funding residents and families to feel resentful and frustrated because of a perceived lack of priority care, despite their self-funding status:

Anne (2): But I mean, who pays for the care, and who doesn’t pay for the care is confidential. And so people on the floor in theory don’t know. I mean, it’s the patient themselves that say, ‘I’m paying for this’, and what have you. But I mean, in theory it’s confidential. And as far as we’re concerned the delivery of the care is the same regardless.

Faye (2): I think the families have definitely got different conceptions. And I hear it all the time, you know, ‘My mother pays x price, and I expect....’, and that’s alright, but just because she pays for it, it doesn’t mean to say that the people who are social service funded don’t deserve the same care. Of course they do.

Secondly, some participants attributed residents’ altered attitudes to funding transitions, i.e. the shift from ‘free’ NHS healthcare to long-term care that requires some residents to

contribute towards their care and residential costs. Participants suggested that this funding transition prompts some residents and families to alter their expectations and attitudes towards care home staff. This phenomenon is particularly noticeable in NuHs which accommodate both permanent nursing beds and NHS contracted beds:

Alice (2): I feel uncomfortable once I realise they’re coming off the NHS floor. And that’s when it hits them, that whatever the assessment team decide, how much money is coming out of their pocket. And that’s when they decide to stop being a bit, you notice they become a bit more critical about the home. Because it was all free before.

Beth (2): I think because a lot of people don’t understand, like if certain relatives have been in hospital and had free healthcare for that long, then come to the [NHS unit] and you say, ‘Oh, your mam needs permanent nursing care’, you know it changes everything, and you can see straight away that the families are, their expectations and everything change...Now they want to get what they’re paying for you know, so sometimes the dynamics can change, between you and the relative.

Participants’ responses indicated that they recognise and anticipate that self-funding leads residents to have altered expectations and attitudes:

Faye (2): If we’re paying for a service out of our own purses, it’s understandable. That’s why I try not to judge them, because I can still understand where they’re coming from, you know.

But, difficulties do arise when participants perceive residents’ expectations and attitudes detrimentally affect their motivation to maintain independence. For example, Barbara and Georgia reported that although some residents have the ability to undertake certain physical tasks themselves, because they are paying for care, they insist on staff intervention. These participants suggested that such residents are potentially foregoing rehabilitation opportunities:

Barbara (3): I think the residents do think they erm, because I mean quite often a lot of people think because they’re paying, you will do, you know you’ll dress them and you’ll feed them, and you’ll do things, when they’re actually more, they’re capable of doing that.

Georgia (2): We’ve got a lady, she’s in hospital at the moment, and we, she came, she’s privately funded, she needs intermittent catheterisation. She said, ‘Are you not going to pull my trousers up?’ I said, ‘Well no, you can do that yourself’. ‘But I’m paying you to do it.’

5.3.3.4 Summary

Participants’ responses cited in section 5.3.2 indicated that in their view, a high proportion of the NuH role focuses on residents’ social well-being. This creates dissonance about the

nature of the role for participants because they are required to undertake some activities that they did not expect, or feel prepared for. This situation creates a level of uncertainty and unpreparedness about role identity for some NuH nurses. The vast majority of NuH nurses are employed in the private sector, and the views presented in the current section of the chapter suggest that role difficulties and uncertainties are exacerbated by the inclusion of business activities within the NuH nurse remit, and that the two themes identified in 5.3.2.3 are also embodied within the business aspects of the NuH role. Findings indicate that although selling and maintaining occupancy are required skills for NuH nurses, they may not have expected, or feel prepared, to undertake these practices. Regardless of whether participants struggle with care/business integration (for example, Cath), or can seamlessly integrate business into the care role (for example, Anne), both groups agreed that the introduction of business training to nurse education practices may mitigate some of the role challenges faced by NuH nurses.

Consideration of the role’s business aspects reveals a further issue. Participants indicated that they perceive the business aspects of their role influence views of NuH nurses. Their responses suggested they themselves are disconcerted by the association of their role with controversial funding issues and profit. Participants also proposed that funding issues can change the nature of nurse/resident relationships.

Discomfort with the business aspects of the role: Some participants stated that care

and business are conflicting concepts, whose juxtaposition leads to moral dilemmas. Others described how they incorporated business activities into their role, but were disquieted by the assimilation, leading them to explain and justify their business involvement. This suggests they are aware that a controversy exists. The findings also suggest that, because residents may be required to contribute to the cost of their care, NuH nurses view showing potential residents around NuHs as an act of selling. Participants’ responses to selling differ. Some refuse to become involved. Others do get involved, not just to provide information about services, but because by performing the activity, they are protecting residents from unrealistic assurances that may arise from the profit-generating motivations of the commercial side of care provision.

Changes to the nurse/resident relationship: As discussed in 5.3.2.2, participants said

that therapeutic relations between nurses and residents/families can be difficult to maintain because these relationships are so close. However, they reported that their relationships with self-funding residents can be complicated further. Participants said that residents who contribute to the cost of their care may become more critical of care services, may expect their care to be prioritised, or may regard staff superciliously. Some participants also

arising from activities of daily living exercises, and may be less likely to get involved in their own care because they are paying someone else to perform these activities. The participants suggested that these behaviours can have a damaging effect on NuH nurses’ abilities to develop therapeutic relationships with residents, utilise rehabilitation processes to maintain residents’ independence, and support resident participation in care.

5.3.4

‘There’s just a big stigma around working in nursing homes’: Nursing

home nursing as a stigmatised role

As well as discussing aspects of their role as NuH nurses, participants referred to their views and experiences regarding their occupational status, and how they thought they were perceived by both the public and other healthcare professionals. Participants reported their view that generally, other people view NuH nurses in an unfavourable light. Throughout the interviews, they spoke about being subjected to negative perceptions, attitudes and behaviours expressed by the public and other health professionals – behaviours which they suggested stigmatises the NuH nurse role (they discussed their experiences using language that refers to stigma, for example, ‘stigmatised’, ‘second rate’, ‘looked down on’, ‘lower option’). Participants proposed that disparaging views regarding the NuH nurse role emanate from a number of possible causes, and they stated that they find being the subject of stigmatising behaviours intensely challenging. Analysis of participants’ responses revealed that they perceived six causes of stigma to exist. These are presented below. After this presentation, sections ensue which discuss the consequences of stigma, and how participants’ responses indicate how they manage stigma.