Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions

Career pathways

One of the recommendations from Cavendish26 was to strengthen the care career trajectory for the support workforce, and there is evidence that a number of health-care support workers aspire to develop their careers. 40 In social care, there is acknowledgement of the benefits of career pathways for support workers, but the picture is mixed. 30 It seems that, currently, the degree of synergy between workforce development and opportunities for job and role development is not always clear. Leadership, supervision and support should be developed in order to get the best out of people. 26,48

Role substitution

Support workers have been traditionally represented as low-cost labour source. 23 In recent times, the division of labour in hospital care has led to delegation of nursing tasks to care assistant roles. 54 Traditional workforce boundaries have altered drastically, with the support workforce taking on tasks previously undertaken by registered staff. 31,38 Although the growth in the support workforce has sometimes been driven by initiatives to reduce costs, involving role substitution for registered staff, there is a degree of evidence to show that support workers can act as an additional resource to enhance older people’s experiences by improving the contact with care practitioners. 35,44 In social care, there is role overlap between support worker and professional roles. 30 When the support worker role is perceived as a substitute for professional nurse tasks,46 this can potentially compromise morale.

Regulation

Regulation for health-care support workers has been debated at length in recent years but as yet remains unresolved. 46 In the UK, a major review of health support workers commissioned in 1999 examined health support workers’ roles and regulation. 55 Core competencies in Scotland were introduced in 2001, which informed further work about regulation for health-care support workers. 56 The current ambiguity about regulation means that there is little control over employment, responsibilities, education, competence, title and pay. 38 In social care, registration of home-care support workers has been recommended,57 with codes of conduct developed for health and social care workers58,59 in addition to governance frameworks. 60

Retention

Consistent employment patterns for clinical health-care support workers have been reported. 40 However, in social care, retention in home care is problematic, with one of the highest staff turnover rates at around 21%, twice the national average. 61 Securing new support staff and retaining those who are already employed in home care should be key priorities. 59 For joint working, staff retention is important, as it has been reported that frequent staff turnover can have consequences for the numbers of staff who champion integration. 16 Recommendations have been made for employers to be supported to test care values at recruitment stage. 26 However, in home care, high turnover demand and low pay can compromise values-based recruitment. 61

Concept mining

Concept mining was undertaken to map evidence about the support workforce, workforce development interventions, older people’s services, how interventions might operate and any reported enablers or barriers to the successful implementation of interventions. Concept mining in realist synthesis describes a process of searching through different bodies of evidence for information that could help build theories. In this review, concept mining involved searching through different bodies of evidence (including the commissioning brief, policy/guidance and grey literature) for information that could build theories about workforce development.

The starting point for the review was the commissioning brief, which was subsequently reflected in the funded proposal. 79 Particular points worth reiterating here relate to the nature of the work of the support worker; how training and support interventions should reflect variety in need across different organisations/settings; the focus of training (task/core competencies vs. values-based approaches); effectiveness and cost-effectiveness; ‘best’ interventions; teaching methods, organisational development and performance management; and impacts of workforce development interventions (for individual support workers, teams and older people).

In a background search of some policy documents,41,60,63 we found literature about the perceptions of support worker roles, gaps identified in skills training, how training and development should be structured for the support worker, approaches to workforce development, professionalism and the working environment. Key concepts identified from this background search included:

• how support workers who feel valued and empowered are more likely to promote dignified care

• how management support in the workplace can enhance autonomy and decision-making

• the challenges of over-reliance on personal experience without specific guidance

• continuing professionalisation of care work so that support worker roles can be promoted

• how personal development can build knowledge and skills

• dimensions of quality, including dignity, communication and understanding of the older person as an individual

• use of multiple, flexible learning and teaching strategies to promote confidence

• increase of the attractiveness of care work through the provision of development opportunities.

To guide our development of the programme theories, we conducted an initial exploration of theory which might help to show how workforce development should work and identify what factors can supposedly support or hinder its success, for example learning from theories of professional learning, which included the role played by informal learning80 and role progression, and the development of expertise in developing learning. 81 We drew on the work of authors64 to consider how the mental activity required for skill acquisition varies from novice to expert (i.e. workforce development interventions should meld with the support worker’s developmental stage). Theories of adult and transformational learning were also relevant to be considered in the context of how interventions may be underpinned by holistic education, taking into account cognitive, affective and psychomotor domains. 82 We also examined how workforce development is defined in other disciplines, for example education83,84 and employment. 85 We considered variation in workforce development implementation for the support workforce,26 issues of workforce changes and substitution31 and how to link different development interventions and workforce functions. 33 Theories of behaviour change were also considered, as they focus attention on how to develop individual skills and knowledge. 86 From an implementation perspective (i.e. literature that might help to explain how interventions/programmes get implemented in practice), we considered how knowledge use may be influenced by factors related to the work environment and facilitation,87 and, from education, how the choice of intervention should suit the context. 88 We also mined the practice development literature to be cognisant of how workplace cultures can be improved. 89 We also felt it important to take into account the role of organisational and other contextual influences that might influence workforce development intervention design, delivery and evaluation, including individual, team and organisational foundations for learning organisations90,91 and other factors which enhance or act as barriers to learning. 92

Conceptualising workforce development

At the beginning of the project we held a workshop in which stakeholders contributed to the development of the scope and issues that are relevant to the workforce development of support workers with older people’s health and social care services (see Appendix 4 for workshop participants). The workshop was facilitated by two members of the research team (CB and LW). Stakeholders were purposively sampled to ensure representation from relevant constituencies (i.e. health, social care, education, third sector, patients and the public).

The structure of the workshop was guided by soft systems thinking, a learning approach which offers an interpretive perspective of the complex and adaptive nature of human systems, such as workforce development, within the ‘real world’. 93,94 Soft systems methodology complements the realist approach used in this review, as it takes into account how complex systems within which programmes or interventions are situated may be underpinned by different perspectives. 95 We found that applying the principles of soft systems methodology helped the team to operationalise the workshop in a structured way. In addition, soft systems methodology helped us to guide stakeholders’ thinking, so that they could shed light on some of the complexities behind workforce development for support workers. We chose this approach as we assumed workforce development to be transformative of both individuals and contexts, with the potential for both complementary and conflicting structures, processes, impacts and perspectives. We applied the principles of soft systems in two ways:

1. the use of the CATWOE mnemonic (see below) to structure data collection, discussion and analysis

2. the generation of rich pictures describing how workforce development works.

The CATWOE mnemonic provided a structured way of thinking about the complexity of workforce development programmes by focusing on the beneficiaries of workforce development (customers), the roles and functions of people within workforce development (actors), the changes that workforce development makes (transformations), the beliefs about what is important in workforce development (world views), issues of leadership (ownership) and physical and other constraints on the system (environment). 95

The first phase of the workshop included table discussions around the CATWOE issues (Table 1).

The output from these discussions was used to develop rich pictures to illustrate the complexity of a workforce development ‘system’ by linking the CATWOE elements, for example:

The rich pictures provided the basis on which to develop a stakeholder-driven textual summary of how workforce development for the support workforce for older people should operate:

• The effectiveness of workforce development interventions/programmes for the older people’s support workforce can span outcomes for the workforce (e.g. knowledge, skills and attitudes, career progression and personal/professional development); for the delivery of services; for older people and their carers (e.g. service effectiveness and experience); and for organisations (e.g. service quality). Interventions/programmes are most effective when positive impacts from workforce development can be identified in all of these areas. For example, changes in the knowledge and skills of the support workforce will often require changes in organisational systems or processes for benefits to be accrued by older people, and vice versa. When these impacts do not meet the expectations of older people or health organisations, then positive, individual changes from workforce development programmes/interventions might be evident but might not be sustained.

• Workforce development will be effective when it is aligned with organisational and other career development frameworks and opportunities. When these frameworks are used to design and evaluate workforce development, benefits for individual members of the workforce may have greater visibility and meaning.

• Effective workforce development is designed, implemented and evaluated with the older people’s support workforce and practice. Programmes or interventions that are neither grounded in the reality of daily work completed by the older people’s support workforce, nor delivered within in the workplace, are less likely to be effective.

• Effectiveness can be mediated by the personal characteristics of members of the older people’s support workforce (e.g. motivation, self-esteem, confidence and learning styles); aspects of human and social geography; characteristics of the organisations in which the support workforce is operating; workforce and service policy; and public experiences and expectations.

Identification of theory areas

This initial conceptualisation was used to generate a longlist of issues in four theory areas for focusing the review (see Appendix 5). These were reviewed and prioritised by stakeholder workshop participants and then by the Project Advisory Group members in a face-to-face meeting. They were broadly grouped into theory areas: career development and strategy, design and delivery, and mediating factors and impacts.

Primary search of databases

The major health, social and welfare databases were searched using keywords identified through the search development and database specific ‘keywords’ adapted for each information source (see Appendix 7 for an example of search strategy). The primary search was limited to material from 1986 (the date of the conception of NVQs) to 2013. Methodological filters were not used to avoid excluding any potentially relevant papers. Systematic searches were conducted in 10 electronic databases subscribed to by Bangor University: PsycINFO; SSA; Sociological Abstracts; MEDLINE; NHS Economic Evaluation Database; Web of Science; CINAHL; The Cochrane Library; Applied Social Sciences Index and Abstracts; and Database of Abstracts and Reviews of Effects.

The searches took place in April and May 2014. References were stored in RefWorks database software (ProQuest, Ann Arbor, MI, USA: www.proquest.com/products-services/research-tools/). The systematic databases search yielded 17,033 references; 4684 of these were duplicates, leaving 12,349 hits included for title screening. Hits for each database are shown in Figure 2. Alerts were set up for the database searches and alerts were scanned up to April 2015.

FIGURE 2.

Results of search and retrieval. AMED, Allied and Complementary Medicine Database; ASSIA, Applied Social Sciences Index and Abstracts; CRD, Centre for Reviews and Dissemination; DARE, Database of Abstracts of Reviews of Effects; DH, Department of Health; ERIC, Education Resources Information Center; HMIC, Health Management Information Consortium; NHS EED, NHS Economic Evaluation Database; NICE, National Institute for Health and Care Excellence; NIHR, National Institute for Health Research; NMC, Nursing and Midwifery Council; RCN, Royal College of Nursing; SCIE, Social Care Institute for Excellence.

Purposive searches

In realist synthesis, a Cochrane-type systematic search strategy is unlikely to yield all sources to inform the testing and refinement of the programme theories. 97

In a review related to complex evidence, only 30% of sources were obtained from the database and hand-searches, while 51% were identified by snowballing and 24% were obtained through personal knowledge/contacts. 98

In the current review, purposive searches of the evidence were conducted to provide specific focus on the programme theories. The primary search for references was augmented by other searches for support worker role evaluations or intervention research which made specific reference to embedded implementation or impact (e.g. around careers, location, settings, skills or outcomes). Purposive searches were also conducted in Allied and Complementary Medicine Database, Health Management Information Consortium, education, policing and the practice development literature. In addition, a hand-search was conducted in the British Journal of Healthcare Assistants. Other papers were added through snowballing, from database alerts and from project group and stakeholders (see Figure 2). Internet-based searches for grey literature were conducted for workforce development project reports, national inspection and regulation quality reports, and evaluative information about these initiatives.

Programme theory testing

To enhance the trustworthiness of the resulting CMO configurations and to facilitate the development of a final review narrative, we conducted 10 semistructured, audio-recorded interviews with stakeholders. We used a mixture of purposive and snowballing sampling to obtain the perspectives of people who would reflect those who would have a stake in the findings. The interviews were structured for the purposes of testing out the CMO configurations, with data confirming or disputing each mapped directly onto the CMOs. The interviews facilitated the development of the final CMO narrative. Our sample comprised managers, directors for training/development and support workers. An interview schedule was developed based on the CMO configurations to elicit stakeholders’ views on whether or not they resonated with their experience, and whether or not and how they might operate in practice (see Appendix 13). All the interviews were conducted by telephone and lasted between 45 and 60 minutes. All interviews were audio-recorded and concurrent detailed notes were made.

The audio-recordings were fully transcribed. As the interviews were structured for the purposes of ‘testing’ out the CMO configurations, data confirming or disputing each were mapped directly onto the CMOs. In fact, the interviews provided mainly confirmatory evidence of the CMOs and provided some additional contextual evidence to each. Evidence from the interviews is combined in the narrative for each of the CMO configurations reported in the next chapter.

Context and mechanism

A strong relationship was evident between the proximity of the workforce development intervention and real-life work of the support worker, and specifically whether their work was immersed or disconnected from the intervention. Proximity was a feature of development initiatives that were closely aligned to the work of the support worker, delivered in practice or closely related to practice. 105–127

Proximity prompted feelings of resonance, when the intervention focused on what the support worker might experience in their work and what was familiar and relevant to them. There were two different forms of proximity in the evidence:

• cognitive proximity,106–110,112,113,115,117–119,121–125,128 which was evident in intervention specifics or content, and judged by the extent to which the applicability of the intervention to the support worker’s own work practice could be observed, and/or

• physical proximity,105,107,111,114–116,120,126,127 reflected in intervention delivery, was physically located in the support worker’s workplace.

Taking support workers out of the workplace for workforce development

We found a different perspective or contradictory evidence around physical proximity, specifically about the positive impacts of removing support workers from their work area, and that learning could be better enabled through the provision of separate space with less disruption. 105,123,131–133

For example, facilitating workforce development on weekend days away from support workers’ jobs was linked with positive impacts about participants’ knowledge and attitudes. 105 An intervention to improve participants’ awareness and knowledge about aphasia, delivered in a college setting, demonstrated improved learning about aphasia. In addition, in this study, participants demonstrated greater incorporation of new learning into their work. Interview data affirmed the feasibility and positive impacts of taking staff out of their work context to participate in workforce development, but noted caution in ensuring no negative consequences for the organisation:

. . . variety and change of scenery does make a difference to people’s learning habits and what they learn and how they learn without a doubt, and I agree with that completely. We also have to do what works well for our organisation, within our care delivery demands as well. So it’s finding that balance.

Telephone interview, participant 3

In two other interviews, reference was also made to the benefits of providing opportunities for support workers to gain understanding of other organisations settings, in which it was ‘interesting to see how different some of the homes operate’ (telephone interview, participant 8) and useful for ‘. . .cross-fertilisation’ (telephone interview, participant 1). Further, from the education literature, we noted reports of interventions which encouraged taking teaching assistants out of the classroom to visit other schools and view different practices. 123

Regardless of the pros and cons of the physical proximity of workforce development, the interviews highlighted the need to think systematically about the delivery location by focusing on its combination of practical or theoretical content:

I think a lot of it depends on the type of training. If you’re going to have an academic session that’s looking at the impact of immobility on tissue for instance, you want to have a session on pressure area care. That can be beneficial in the care home setting, so in [xxxx] there would be some quite logical sense in doing that because you can then say, OK we’re going to go along and see so and so after we’ve done this and we’ll look at our tissue areas and their pressure areas and we’ll look at the colour of them, we’ll look at the state of her skin, we’ll look at the state of her hydration and nutrition, and you can then make the training wheel. That kind of training I consider to be essentially practical. If you’re looking at something that’s perhaps more theoretical, going to talk about say, let’s say it’s going to be the impact of certain drugs on someone who’s got vascular dementia, the effect they’re going to have . . . that works quite well in more of a classroom setting because you can focus, you won’t have the distractions of being in your workplace, you won’t have call bells going off, you and your students will be able to concentrate on the academic side, the technical and the academic rather than the practical.

Telephone interview, participant 9

This interviewee went on to describe the positive personal impacts for support workers that taking them out of the workplace might bring, when ‘taking someone away from their workplace and sending them to somewhere, as a novelty value, creates a break. And that in itself is quite a positive thing’ (telephone interview, participant 9).

Taking participants out of the context of practice may also have implications for continuity of learning, in that learning that has happened away from the setting may have to be reinforced when back in practice to ‘make it real’.

Outcomes

Proximity in workforce development, in either a cognitive or a physical sense, prompted resonance with the individuals participating in it and/or was more likely to lead to cognitive and/or practice changes. Cognitive impacts for support workers included empowerment114,127 and improvements in self-esteem,114 together with increased knowledge and understanding of the behaviours of older people in their care. 108 When interventions were proximal through the use of person-centred training, role play and homework, this led to changes in support workers’ mental models of their role and work. 117,124 For example, coaching in the workplace led to an ‘ah-ha’ moment for one care assistant and a positive difference in a care home resident’s behaviour as a result of the changes in behaviour of the support worker. 117

Practice changes included better cohesion and paying more attention to older people in efforts to meld theory and practice,111 and improved relationships with family members. 113 The use of real-life case studies of older people in residential care settings, as well as visual tools and storytelling, also prompted resonance with the support worker’s practice. Improvements in the appropriateness and adequacy of care, including for those older people with the greatest needs, were affected after intervention. 121

In situating interventions in the workplace, practice changes as a result of making learning more real for the support worker included more attention being paid to older people111 and relationships with family members improving,113 as well as more general aspects of service quality; for example:

Following completion of the educational programme, there was significant increase in the proportion of care that was judged appropriate and adequate provided by healthcare assistants to residents than before.

p. 8121

Summary

In this CMO configuration, we found that a relationship between the cognitive or physical proximity of the support worker and the workforce development prompted resonance with participating individuals which was important in terms of potentially influencing positive cognitive and/or practice changes. The relationship between proximity and resonance was made visible through the use of tools and techniques to draw on real life, supervision of practice, working together, and evidence to prompt understanding and appreciation of older people themselves.

Context and mechanism

There were numerous examples of workforce development interventions paying attention to support workers’ personal and professional perspectives, previous career, age and experiences, values and perceptions of older people’s services, abilities, expectations and life skills. 106,107,109,113,121,122,129,130,134–140 We were able to trace an evidence thread between tailoring to these factors and engagement with the intervention, as the support worker is able to appreciate what is expected of them in the context of ‘where they are at’. This finding was also reflected in interview data. For example:

. . . a lot of what we’re trying to do is get people to see that the skills and talents that they have outside of the service . . . things that can be brought to work. Maybe other residents are interested in these things, maybe they can support all different parts of life of the home and not necessarily just doing their set job, and in that way you can sort of, contributing to the sense of it being a whole home approach, having a thriving community and having a lots of different kinds of varying activities going on in the service.

Telephone interview, participant 6

Starting points included experience of work within older people’s services, as exemplified in this excerpt from a report of a gerontological training intervention,132 in which ‘sessions were experiential as well as didactic, drawing upon trainees’ experiences and challenges; this set the tone for interactive skills which “role modeled” communication skills for interaction with clients and families’. 132

A broad range of individual attributes was evident, on which successful interventions were constructed including emotional resources. The value of harnessing existing support workers’ emotional strengths and personal resources to enhance the effectiveness of workforce development activities was evidenced in examples of interactive training processes and interventions. In one example, in the context of ‘. . . often a lack of training in emotional issues, and especially in working with residents’ families’113 a workshop-style training intervention for staff in long-term residential care based in Australia113 included affirming participants’ existing strengths and skills. Analysis of the participants’ feedback demonstrated how life experiences were valued and used to explore how they managed the emotional aspects of their work.

In a short programme aimed at sensitising nursing assistants in a long-term care setting to ageing and the experiences of older people,129 the intervention focused on the self and reflection, including linking this to individuals’ existing values:

During the introduction, an exercise entitled ‘As We Grow’ was used to elicit an atmosphere conducive to self-examination. This exercise required participants to write down seven of the most important things in their lives (i.e., people, animals, careers, possessions, etc.). 129

Extending beyond self-awareness, workforce interventions to teach person-centred care-giving skills to support workers also indicated benefits in the workers’ emotional engagement with older people. 109 Person-centred caregiving was associated with interpersonal complexity, or support workers’ abilities to view older people in ways that are not stereotypical. The intervention included discussion about the importance of identifying how individuals perceive others and found that ‘cognitive complexity is associated with motivational factors, such as the goal of forming personal relationships with residents. Being able to select talented caregivers would be of direct benefit to facilities and could reduce the need for training’. 109

Other attributes accounted for in workforce development included individuals’ earlier life or work-related experiences of learning. An evaluation of a simulation-based intervention demonstrated that both previous experiences of formal education and a reliance on experiential learning about the support worker role were instrumental in influencing support workers’ learning experience. 122 This was highlighted by a ward manager reflecting on the programme that ‘in the past most [support workers] have learned with time, and through experience, working alongside trained nurses, knowing the expectations of the trained staff. That’s probably time served . . . experience’. 122 Interviews with service managers confirmed the importance of experience and age in tailoring workforce development to the individual:

So we actually look at what the individual has achieved already, and then we match that up with things that they could also do . . . that they’ve not done for whatever reason . . . we do take a lot of interest in each individual.

Telephone interview, participant 5

In addition to acknowledging the role of emotional attributes and prior experiences of learning, some evidence targeted the mental models that support workers held about the nature of care settings, services and older people. 124 In a case study set in a residential care in the USA, two mental models (described as the ‘golden rule’ and ‘mother wit’) were identified as guiding certified nurse assistants in their work and their interactions with older people. Understanding individuals’ mental models, because they ‘might not be a good basis for appropriate care actions’,124 can be a starting point for reframing them.

Although not linked specifically to workforce development, an acknowledgement of the importance of personal resources was reflected in the non-health evidence. In a report of a research study about the police community support officer (PCSO) role in England, we found a similar pattern between the age and life experiences of the support officers and their effectiveness within the role, which appeared to be easier for ‘the older PCSOs – those who had a wider range of life experiences from which to draw. This is not to say that the younger PCSOs were not effective in the role – they were, and they often seemed to be more at ease behind a computer screen than their older colleagues’. 140

Abilities

Our second interview participant raised the importance of paying attention to individual ability: ‘there’s something about acknowledging the stage that learner is at in their career or their learning pathway’ (telephone interview, participant 2). There was also evidence of drawing on individuals’ own abilities in the design and evaluation of workforce development. Individuals’ communication skills were the focus of a training package for care home staff to enhance their interactions with older people,139 and in a critical analysis of a communication skills training programme for nurse aides set in the USA. 138 The effectiveness of communication skills was assessed prior to the intervention during 5-minute care interactions with residents, using a communication skills checklist. This was also important in establishing that ‘an increase in the use of effective skills and instructions, and a decrease in ineffective instructions by [support workers] during care interactions and maintenance of these changes for 3 months’138 had occurred.

Evaluation of a computerised educational programme for nursing assistants in end-of life care134 included exploration of ‘the following characteristics: 1) ease of use; 2) clarity of presentation; 3) appropriateness of reading level and content; and 4) relevance to nursing assistant practice’. 134 In this example, the use of learning approaches that paid attention to the existing abilities of the nursing assistants in literacy and language were explanatory:134

. . . needs of users with low literacy skills and diverse learning styles are addressed by incorporating slides, art (line drawings or illustrations), video clips and audio clips. Other features to increase ease of use for those with diverse learning needs include a glossary, indices, a simple search engine, and self-grading quizzes.

p. 504134

Similarly, in a work-based learning programme for support workers in assisted living based in Oregon, USA,135 paying attention to literacy and language needs enabled the intervention planners to factor in additional time to maximise the effectiveness of the programme for staff.

Role expectations

We also found that the design of some workforce development interventions supported the sharing of individual expectations about the support worker role. Participation in a simulation-based educational programme required support workers to express their own expectations about their role development. 122 Interventions promoted the career development of support workers, including the use of job analysis to understand existing and required competencies for the role. 135 Other interventions focused on career progression, incorporating principles such as professionalism, self-efficacy, self-worth and maximising intrinsic motivation,132 so that the design was ‘grounded in an intention to encourage a more career-focused orientation’. 132

Outcomes

Situating and tailoring workforce development in the context of the personal and role starting points and expectations of support workers was more likely to prompt commitment, leading to increased levels of engagement with the intervention and potentially with the older people’s service. This was achieved through improvements in team working, clinical knowledge and skills, and relationships with residents. 141 For employers, impacts were in terms of better management of challenges,105 including support workers being ‘more creative in handling challenges that come up for them’. 105 Through a cycle of reinforcement, these impacts appeared to extend to a better appreciation of staff by family members:113

The results may also suggest that when staff members feel more appreciated by family members, they feel more able to have cooperative conversations and feel more empathy. The above can lead to staff forming better and more cooperative relationships with family members, which may improve their working life.

p. 319113

In an intervention which featured self-assessment and lifestyle change for the support worker, caring for themselves could help support workers to better care for older people, expressed through increased feelings of worth and belonging. 107 In another intervention designed to promote a career-focused view and enhance professionalism, self-efficacy and self-worth, a deeper commitment to care work was found. 132

Personal outcomes related to more confidence, pride and feeling rewarded141 and valued. 142 These outcomes also emerged in interviews, but were linked to service improvement, for which one manager felt that it ‘is as much about the worker, as it is about the resident, and it works because they feel valued. It’s reciprocation, I mean look at, it is, if you treat somebody as a human being and you listen to them and you really, really support them to do their best, they start to totally reciprocate with residents’ (telephone interview, participant 1).

Summary

If workforce development pays attention to the individual support worker’s personal and role starting points, for example personal resources, abilities and personal feelings and expectations, then this leads to increased levels of engagement with the intervention. Workforce development interventions can examine support workers’ personal resources, build on, recognise and value different abilities, and harness existing resources in development activity. In addition to engagement with the intervention, this may enhance support workers’ engagement in their service. It also leads to personal outcomes such as confidence, empathy, self-esteem and satisfaction, which may be linked to other outcomes for older people, families and services.

Context and mechanism

Incentivisation was noted to be a strong thread within the analysis, interpreted as efforts within the design and delivery of interventions to motivate individuals and to ensure attendance at, and completion of, the intervention. These efforts included certification to recognise engagement in interventions105,120,127,140 and the use of prizes112,138,143 and financial incentives. 106,127,133,141,144

In its simplest form, we found evidence that the use of ‘certificates of attendance’ triggered a sense of reward105,120,127 through the branding, badging and accreditation of the intervention that support workers were taking part in. This excerpt of interview data reinforces the link between acknowledging participation in workforce development and individuals feeling rewarded and motivated:

And I remember one person saying to me, do you know what, I’ve never had a certificate for any work I’ve ever done before. Never at school, never got anything, now I’ve got two certificates in one day I can’t believe it. You know, it motivates some people. Even if it’s only for a couple of days or a couple of weeks or whatever, because before they know it they’re on the next course, and remember how well you did on that one, let’s see how you can do on this one.

Telephone interview, participant 5

In a communication skills programme120 and an intervention to recognise depression in care home settings,127 certificates were also used to recognise completion of the intervention. Successful completion of a short curriculum for direct care workers (described as nurse aides, personal assistants and adult day-care assistants working in older people’s care), set in the USA, resulted in completion certificates for the participants being provided, but these were designed to be relevant for employers in the local area. 105

From the policing literature, we found supporting evidence that certification should be offered to recognise support officers’ development of skills and abilities:140

. . . when a PCSO contemplates leaving the organisation to move on to other work, many are left with the impression that they ‘have nothing to show for it’ when it comes to their experiences as a PCSO. Many of the abilities they have gained are of course transferable to other organisations.

p. 23140

Theoretically, certificates of engagement and achievement in workforce development should increase prospects for those support workers who wish to progress within or move between organisations. However, we found little evidence that examined the consequences of this type of incentive mechanism, other than in the above aspirational excerpt from the policing literature.

Other than rewarding attendance and participation by certification, other incentives were used to motivate support workers to complete and engage in ongoing workforce development programmes. Practical approaches included public posting of progression reports for support workers and using prizes as rewards for specific performance targets. 138,143 In an intervention in which support workers were taught to use communication skills with residents with cognitive impairments, a comprehensive staff motivational system was used to encourage individuals to sustain their new performance and skills. 143 Some incentives were designed to include an element of choice, so that the prize was more relevant for the individual choosing it. However, in the example below, the personalisation of incentives within a lottery-style draw was constructed in addition to a public recognition of performance:

For each shift, the individual winning the lottery was provided with his or her choice of incentives from a list of choices determined by each nursing home . . . Across nursing homes, the most frequently chosen incentives were the opportunity to leave work earlier than scheduled, extra pay, and goodie bags.

p. 453143

Lottery-style approaches to incentivisation featured in other evidence, including a development to incorporate ‘Informed Teams’ (a specific programme of staff development in care home settings which integrates skills in routine practice with staff development to meet staff’s needs) as a vehicle for staff development in care homes. 112 Weekly draws and prizes were used to encourage staff participation in daily meetings and skill sessions, as well as other incentives used to encourage engagement by the participants. Lottery reward systems were also associated with intervention tasks in the case of the completion of self-monitoring documentation. 138 The impact on staff engagement was evident by the fact that when the reward system was withdrawn, compliance with the self-monitoring task decreased significantly. In this context, lottery-based reward systems may be successful only in raising awareness of expectations of workforce development, rather than in affecting more fundamental and sustained cognitive and behavioural changes. From interview data, we also found that there was an impact in terms of staff feeling recognised and rewarded if incentives were offered:

. . . it may seem insignificant to others unless you’ve ever been to one, we do a presentation every year for the learners and the staff who achieved, we have something called the smile award. And it’s a little initiative that I find that . . . makes the difference. And we’re not giving them £50 bunch of flowers, we’re giving them a nice pen, certificate and a badge and they love it.

Telephone interview, participant 7

A range of different organisations used monetary investment to engage the support workforce with development. The evidence to support the use of financial incentives was limited to some North American and European settings,106,133,141 and so may reflect particular professional and service contexts. A financial contribution from the support worker, such as a small course fee to attend a clinical module,106 could also lead to a sense of personal stake in the workforce development/intervention. Financial incentives or remuneration from workforce development budgets were generally noted to be directed towards support workers’ turning up. 106,127,144

Financial incentives or remuneration from workforce development budgets were also noted to be directed towards support workers’ completing interventions. The ‘Win A Step Up’, a programme of continuing education by on-site trainers for nursing assistants in care homes in North Carolina, was designed to decrease turnover and improve quality of care. 141 The programme reported using financial incentives in the form of staff bonuses to ensure successful completion of the intervention.

An intervention that included peer mentorship for care assistants in a care home setting used the financial incentive of a 10–20% increase in peer mentors’ salary, or overtime or a reduction in workload, in recognition of the additional work that the mentors took on. 133 We also found reference to financial incentives being used to reward enhanced skills in stakeholder interviews: ’. . . we reward, once staff attain a certain level of skills and experiences, we reward that through pay’ (telephone interview, participant 3).

Outcomes

Monetary incentives were reported as generating positive impacts for the individual support worker. For example, managers reported support workers’ enhanced confidence and pride and feeling more rewarded,141 and self-esteem. 144 Outcomes from lottery-style incentives were related to personal engagement with the intervention (‘generate excitement’ about the project intervention strategies112), their work and the organisation in the development of a culture in which ‘. . . the work environment supports skill use with constructive feedback and recognition’112 (p. 254).

There were also reports of positive impacts on the quality of support workers’ interactions with patients’ relatives from interventions which included evidence of incentivisation. 144

When communication skills training used a motivational system which included prizes and perks, the outcomes included increases in positive staff behaviours that were also sustained over time. 143

Summary

We uncovered a number of ways in which engagement in workforce development was incentivised for support workers, including the use of certificates, prizes and perks or financial/monetary investment. Incentivisation may make it more likely that participants will feel that they have a stake in the intervention and feel more valued and motivated to participate, which can lead to better engagement with the intervention. Lottery-based incentives on their own may not trigger sustained changes in desired workforce development outcomes and the use of financial incentives may be effective in only some service and professional contexts. There may also be a case for tailoring incentives to make them relevant to the support worker.

Context and mechanism

When the organisation’s strategic direction was made explicit in the reporting of how workforce development interventions were developed, this generally showed alignment with the intervention’s aims. There was evidence of joining up the organisation’s human resource strategy with support workers’ development needs. 142 This included the development of leadership roles for senior support workers and preceptorship for new staff,110 coaching roles to ensure that support workers can benefit from coaching,117,124 supervision,109 appraisal systems140,145,146 and mentoring. 127,147,148

Other ways in which organisations prioritised development for the support workforce included reference to policies such as a mandatory attendance policy,112 allocating time for workforce development112 and general efforts to develop support worker roles through bespoke workforce development strategies. 117,126 Examples were organisational direction/goals to describe care management priorities that were important to the organisation, for example quality of care. 108

However, we noted how the success of workforce development interventions was often contingent on how the organisation prioritised quality improvement. 112 For example, in a report describing the development and pilot testing of a 6-week intervention for certified nursing assistants,108 the authors explained how the intervention aimed to ‘identify and operationalise person-centred caregiving behaviours’. 108 In this way, the intervention was set in the context of organisational efforts to improve the quality of long-term care more broadly, through focusing on relationships and promoting culture change within care settings.

Some interventions, including an advanced education programme for nursing assistants in care home settings110 and the development of a curriculum for paraprofessionals,142 were based on the needs of the service providers. We also found studies that assessed the feasibility of interventions for support workers to recognise depression among residents in care homes for older people. Here, support for staff to receive the intervention echoed the organisation’s direction following concern from managers. 127 In another example,110 the aims of the intervention were aligned with the interests of external stakeholders (in this case, colleges of health-care education) in improving services.

Aligning support worker development with the strategic aims of the organisation was also evident in the context of paying attention to the integration of health and social care. For example, a report of an in-reach team project described the aims to develop a group of carers and support them in their role in integrated care for the older person. 149 The benefit of developing the intervention to meld with the organisation’s strategic direction in this case supported previous research findings about the benefits of up-skilling support workers in integrated care. We also found, in a paper describing the implementation of a support worker role in general practice, evidence to support linking support workforce development to the organisation’s ethos about interprofessional working. 147

Outcomes

Alignment between the organisational goals and workforce development interventions had the potential for greater sustainability because the type of impacts realised could lead to longer-lasting effects, for example enhancing support workers’ commitment to their work,108 promoting better understanding of their work,145,149 helping to develop positive attitudes,142 promoting more tolerance and more interest in residents’ behaviours,127 enhancing self-reflection117 and leading to improvements in knowledge. 110,152

Alignment of organisational human resource strategies and intervention design appeared to lead to better outcomes in terms of staff turnover and retention. In this extract, the choice of competency-based programmes which enhanced the competence and confidence of the support worker was perceived to be effective in increasing job satisfaction, retention and career progression:

. . . develop work-based learning programs that move low-wage frontline workers up health career ladders by improving skills and knowledge. The initiative focused on developing competency-based training programs that would increase job satisfaction, staff retention, and career advancement and improve quality of care . . .

p. 283135

Summary

Aligning workforce development with the organisation’s strategy has the potential to be reinforcing, in that the context and content of development are relevant to the goals of the organisation. This reinforcement has the potential to lead to longer-lasting types of impacts for the individual and the organisation, thus enhancing the sustainability of the investment made in the support worker’s development. However, there was little evidence in this context of a ‘joined-up’ approach to a workforce development which linked learning with opportunities for career development, personal growth and monetary and other rewards for skill and role development.

Context and mechanism

We found that a key factor in intervention design was the make-up of the people involved in it. The significance of getting the right mix of people involved in the design of intervention/development programmes was made visible through reports of:

• design involving partnership and involvement of charitable trust funding141 and partnerships with specialists,115,142 multiagency collaboration in the design of programmes/interventions (e.g. joint project work132), collaboration with academic staff150 and communities (e.g. continuous care retirement site109)

• use of expertise128,151 in design (e.g. expert panel,152 professional teachers,128 core curriculum designed with national experts134 and involving people with experience106,150)

• involvement of relevant staff in design,111,113,153 including the support workforce (e.g. intervention design based on interviews with nursing assistants132).

Partnership between organisations

When there was partnership working between different agencies in the design of workforce development programmes/interventions, a co-design approach was reflected in the reporting. A workforce development programme for nursing assistants in care homes set in the USA was described as an established partnership with established goals:141

The program is a partnership between the North Carolina Department of Health and Human Services and the University of North Carolina Institute on Aging.

p. 72141

Similarly, in a report of a skills development programme for direct service workers,132 the authors describe the extent of the multiagency collaboration involved, and how taking a co-design approach informed the development of the intervention because it brought ‘together the strengths and interests of multiple parties in academia, provider agencies, and professional associations garnered statewide support for the effort and ensured that concerns were addressed’. 132 This was discussed in the context of the development of a state-funded training curriculum (which focused on improving problem-solving, communication and stress management skills, in order to increase professionalism and self-efficacy) for care staff. 132

We found examples to show how partnerships were formed with academic and community partners in a collective approach. For example, a 6-week college-based course, which constituted part of the preparation for support workers in the care home sector to achieve the NVQ award, was developed, designed and delivered within a higher education institution in London. 150

In a report of a pilot study that described the development and evaluation of a 2-hour programme for trainee nursing assistants to promote person-centred caregiving skills with older people, collaboration with community partners was instrumental in developing ‘an operational definition of person centred caregiving’109 for trainee nursing assistants.

Partnerships with the right individuals

Paying attention to the intention of the intervention related to who was involved in the design process. We found that the intent behind collaborative intervention design was often twofold. For example, planning an intervention for support workers to develop their skills to deliver the right care was also aimed at supporting their personal development. 151

Similarly, ‘Recognition, Respect, and Responsibility: Enhanced Care Assistant Training’ was developed as a curriculum for nursing/home care aides to improve problem-solving and communication, in addition to developing stress management skills in order to increase professionalism and self-efficacy:132

Underlying the curriculum development was an emphasis on four self-efficacy-enhancing methods: mastery experience, modeling, social persuasion, and altering emotional states . . . The ultimate goal was to empower the direct care worker not just in terms of skills enhancement but to increase their overall perception of self-worth.

p. 116132

In a community-academic project to deliver a gerontological intervention training for paraprofessional service providers,142 the design of the curriculum involved the trainees themselves selecting the topics, and social workers with training in older people’s care were involved in the development and delivery of the intervention. A policy of drawing on people’s experience and expertise was reflected in the report of developing curricula, including trainers holding a Master of Social Work degree related to gerontology and experience of working in a gerontological practice setting. 142 This approach enhanced a collective view about what needed to be done.

Similarly, in an action research study that explored and developed quality end-of-life care in two nursing homes using reflective debriefing groups ‘. . . to encourage open dialogue using the oral tradition of healthcare assistants’,115 groups were led by a researcher who was a nurse specialist in palliative care. 115 We also found evidence of curriculum content in which design was supported by national experts in the topic136 or topic experts in gerontology. 128 In one example, a factor of significance for the programme’s success alluded to by the authors, was the credibility of the contributors to the curriculum design because they were ‘national experts in palliative care and staff education’. 128

Other evidence pointed to the significance of involving the most appropriate staff in the design of interventions, including the support workforce themselves. For example, certified nursing assistants were included on a multidisciplinary expert panel to develop an educational programme for one faculty. 151 Elsewhere, the evidence supported the principle of consulting with staff. 113 In a report of an educational programme for nursing assistants working in long-term care nursing assistants, the programme was designed by an expert panel including a physician, a nurse practitioner, a nursing assistant, a palliative care nurse, a hospice director and an administrator. The authors suggested that the addition of the support workers enhanced the quality of the programme because ‘Participants suggested improvements to the content and format of the workshops, especially the provision of more concrete and practical strategies for working with families’. 113

Support worker engagement was also evident in the co-design of a framework for career progression for health-care support workers incorporating three phases of continuing professional development. 151 The programme was organised and co-ordinated by a dedicated support worker training team comprising four registered nurses plus senior support workers in the role of peripatetic NVQ care assessors.

Complementing the attention on involving support workers, interviewees also highlighted the significance of involving family members in the design of workforce development; for example:

. . . very often they (relatives) will have, sometimes even more of an influence we find because very often older people themselves will not like to cause trouble, will just want somebody who’s kind to them, whereas actually the relatives will often come in with a slightly dispassionate view and have different expectations and standards. And so their input I think is really important. In terms of design I would say, again where I’ve worked in the past these things are often designed by a learning and development team of experts, but actually involving staff, managers and residents and relatives gives it a far richer input.

Telephone interview, participant 2

Outcomes

Having the right mix of people engaged in the design of workforce development programmes/interventions prompted co-design and a collective view about aims and objectives. For example, a programme funded by a charitable trust enabled the team to work together to assess the support workforce and develop a workforce intervention to improve their job satisfaction and retention. 141 When intervention design and development engaged with the right people, such as one example that drew on a dedicated support worker development team including registered nurses and support workers in the role of assessor,151 this implied a more collective approach and streamlined pathways, including linking theory and practice.

When the evidence led to our conclusions that getting the right mix of people involved in the design of interventions can prompt co-design and a collective view, workforce development was more likely to be credible, meaningful and relevant for the support worker, and promoted the potential for positive practice change, as reflected in reports of individual and practice changes.

Summary

In this configuration, we found that the right mix of people engaging in the design of workforce development can be instrumental to the impact of the intervention on the individual support worker and his or her practice. When a collective approach to design is visible, workforce development is more likely to be meaningful, credible and relevant for the individual, and adds potential benefits for practice.

Context and mechanism

Evidence related to engaging with the right mix of people in the delivery of workforce development was noted to provide opportunities for learning together and promote cohesiveness. Having the right people in intervention delivery could be interpreted in terms of who they are and approaches for learning or ‘journeying together’. There was also evidence about the different benefits of bringing different groups of staff together to participate in workforce development alongside support workers.

Outcomes

In the evidence that we found linked engaging with the right mix of people to deliver workforce development and learning together, outcomes related to stronger cohesion across groups105 and sharing of experience. Data from interviews also showed that ‘having a good cross-section of people who’ve got an interest is key to the whole success of the training’ (telephone interview, participant 4). In a report of a 24-hour curriculum for non-clinical direct care workers caring for older people,105 in which different groups of direct care workers undertook the intervention together, the findings found that participants:

. . . expressed increased feelings of worth and belonging (e.g., ‘I liked meeting others like me to share stories, and I feel more understood’)

p. 122105

There was also evidence to link learning together to less duplication of effort and a greater understanding of others’ roles, impacts on residents’ perceptions of care, and improvements in skills and communication during interactions with residents. 128,138

Summary

There is evidence to suggest that if different groups of people are engaged in delivering workforce development interventions then learning together can lead to greater understanding of others’ roles, and potential impacts on residents’ perceptions of care. The ways in which ‘journeying together’ was made visible included through the use of internal facilitators and credible people and by bringing people together through joint sessions.

Context and mechanism

In this configuration, we were able to trace an evidence thread around the impacts of a clearly articulated predefined theory/planned approach and a more systematic approach in the design and delivery of workforce development. We found explicit references to the use of models,112,128,132,133,155 theories112,113,132,136,144 and frameworks,115,136,155–157 linked to the methods then used132,153,156 in three key areas:

1. the development of the support workforce contribution to services

2. the individual support worker him- or herself

3. the delivery of workforce development itself.

Outcomes

The design of a workforce development intervention to enhance the communication skills of paraprofessional caregivers in dementia care was underpinned by Brooker’s VIPS model of person-centredness. 128 This model incorporated four elements about person-centredness in dementia care: valuing people with dementia, recognising people with dementia as individuals, acknowledging people’s perspectives and promoting a conducive environment to optimise well-being for people with dementia [V (value), I (individualised), P (perspective) and S (social environment)]. 128 In this example, the model was used as a heuristic to help participants thread together the themes of the programme and their learning. Utilising the person-centred and hope themes within the model to measure specific outcomes highlighted the impact of the intervention and provided an opportunity for learning about workforce development effectiveness. 128

Explicit reference to theory was also visible in evaluation reports of interventions that focused on personal development for support workers. 144 For example, in a report of an evaluation study of an intervention designed for auxiliary and assistant nurses, stress theory illuminated the potential of reducing work-related stress for the support workers through enhancing their control over their work:

. . . strengthening staff resources of job control, work support, and learning (Karasek and Theorell, 1990), as well as attaining new coping skills, is health promoting

p. 354144

Furthermore, the use of stress theory in a planned approach led to greater potential to demonstrate impact as it illuminated learning about factors that can affect support workers and how they can be empowered.

Summary

There was evidence of both implicit and explicit use of theory and planned approaches in workforce development, in relation to the development of the support worker contribution to services, their personal development and the use of specific learning methodologies. The use of theory could be associated with taking a more systematic approach to workforce development, which meant that the achievement of learning outcomes was made more obvious within programmes. We expect that this is a key requirement for wider programme evaluation and process learning about workforce development.

Context and mechanism

There were some examples (but these were limited) of workforce development interventions which demonstrated a more comprehensive approach, for example by not only incorporating the individual support worker perspective, but addressing their role within groups, teams or the organisation as a whole. In these cases it appeared more likely that attention was focused on how interventions can reinforce one another. This finding was prominent in papers which featured, alongside the reporting of the intervention, evidence about innovation leadership, mentoring, supervision and team functioning. 112,117,132,133,141,144,154

Outcomes

The evidence shows how factors related to team functioning and organisational factors can enhance the potential for impacts to spread across organisations. In the papers in which we uncovered evidence about team functioning, examples of impacts that could be embedded included better management of challenges by staff,105 changes in job performance132 and improved ability to demonstrate empathic and reliable behaviours and relational care. 136 From the evidence in papers which highlighted organisational factors, we found that outcomes related to supporting staff and improving retention,133 supporting leadership141 and improving quality of care. 163 There is also evidence to suggest that particular interventions, such as ongoing supervision, mentorship and coaching, can promote longer-lasting impacts. 109,117

We found limited examples of whole-system approaches to development; the exception to this would be practice development-type programmes. 163 This intervention works at multiple levels (individual, team and organisation) and in doing so has the potential to lead to impacts at an organisational level, which could last longer than one-off interventions aimed at the individual support worker.

Summary

Workforce development programmes/interventions that are comprehensive (i.e. multilevelled/multicomponent) have the potential to prompt attention to be paid to the way in which interventions/activities reinforce one another. This approach could lead to the potential for embedding workforce development and scaling up, so that the impact is felt across organisations. Scaling up is made visible through evidence that shows team functioning features, and when attention is paid to organisational factors.

Strengths

We consider that the methodological approach used in this review was a key strength. As is the intention in a realist review, we have developed a theory-driven explanation of how workforce development for support workers might work, in the form of eight CMO configurations that make up a programme theory. Realist review is not concerned with developing statements or recommendations that have statistical certainty about questions of effectiveness or cost-effectiveness. Traditional approaches to evidence synthesis generally rely on a statistical analysis of the findings, for example the confidence interval around effect size. The philosophical underpinnings of realist reviews necessitate a focus on theoretical depth, breadth and transferability. It would be inappropriate, therefore, to produce a quantitative account of the contribution of each CMO configuration within the programme theory. However, we have paid attention to the weight of the threads of evidence (stakeholder views, published literature and interview data) across the programme theory. This was an accumulative and deliberative analytical process across phases of the review, which we have attempted to document in a transparent way in Chapter 2. The programme theory framework we have developed can be used to guide support worker workforce development initiatives/programmes in the future, pointing to what should be paid attention to and what might work: that is, it provides a plausible and credible account of what works, how, why and in what circumstances.

Realist review takes a particular position on how research quality is judged. 78,195 Rejecting the hierarchy of evidence in favour of an approach that facilitated a search for ‘nuggets’ to help us build up an explanation of how and why a workforce development programme or intervention may or may not work, we did not reject evidence based ‘simply’ on quality. In our extraction process we included trigger questions relating to ‘fidelity’ (did the evidence link to the theory areas?), ‘nuggets’ (did the evidence provide valuable information?), ‘trustworthiness’ (can the evidence be relied on?) and ‘relevance’ (does the evidence contribute to the review?). These trigger questions formalised our approach to coming to a decision about evaluating the usefulness of the evidence to the review.

Another strength of this review was the embedded approach to stakeholder engagement, including with PPI representatives and in novel ways through, for example, the use of Twitter and a Twitter chat. Adjunct to the study website and blog, we operated a Twitter account as suggested in a project advisory group meeting, which provided a communication channel about the study’s topic and fostered additional networking with relevant stakeholders. As part of the networking, we were invited to lead on a @WeNurses Twitter chat about workforce development for support workers. A member of the project advisory group hosted the chat, which was useful to elicit the views of the nursing community and inform ongoing discussions. The chat also led to networking with practitioners with a vested interest in the topic area. A summary of the main points from the Twitter chat is provided in Appendix 2. This facilitated the development of a credible account, while helping us to mobilise knowledge about the work throughout the lifetime of the project.

Limitations

In realist terms, findings are contingent on there and then conditions from stakeholders’ perspectives and as reported in the evidence base. We acknowledge that decision-making at key stages in the review process in this review rests with this unique team and group of stakeholders. However, we have paid attention to providing a transparent account of our approach in this review including a clear audit trail. Although we have identified the junctures at which key decisions were made, it would be impossible within the confines of this report to provide an exhaustive account of the day-to-day decisions we have had to make as part of undertaking the review. Readers should have some confidence in the fact that the review has been conducted by a team experienced in realist review using an approach to decision-making that has been team based (LW, CB and JRM), as well as a decision log/reflective diary. We sought additional support for decision-making from the wider team in our regular monthly meetings.

We suggest that a limitation of this review is the extent and detail of the evidence that we were able to access. As described in our funded protocol, we drew on a wide range of evidence to inform the development of this explanatory account, including from literature outside of health. We had expected, given the prevalence of support work roles in other public services (in the case of this review, policing and teaching), that the available evidence base would be larger. We used relevant networks and key contacts to ensure that we were not missing any key pieces of evidence, and this led to the discovery of some reports. These reports and other sources of evidence from these public services tended to be descriptive rather than empirical.

Reflecting on the nature of the evidence base that was included in the review, overall we found that reports of studies evaluating workforce development interventions tended to lack detail. Specifically, these reports tended to lack detail about the interventions that were being evaluated; for example, authors would state that ‘care planning’ or ‘vignettes’ were used, but did not provide details about these approaches/tools. In addition, we found a lack of specificity in reports about what were the perceived and actual intended impacts from the workforce development initiatives being implemented and/or evaluated.

Implications for practice

The following implications for the practice of designing and delivering older persons’ support workforce development interventions are directly related to the eight CMO configuration of the programme theory:

1. Workforce development programmes should be organised to reflect the realities of the support worker role and work in a number of ways; for example:

   1. Inclusion of material and examples drawn from the reality of practice, for example vignettes, care planning, role playing, stories, theatre and drawing on the experiences of older people, in addition to building on the ‘oral tradition’ of support workers.

   2. Integrating learning within the expectations and boundaries of the role that support workers have, such as designing learning opportunities through, for example, (self-)assessments of where the support worker ‘is at’ in relation to their career/work ambitions, including the ambition of coming to work to do ‘the best that you can today’.

   3. Bringing learning into the workplace on a sessional or integrated basis. This may be more or less relevant depending on the need to access expertise to support learning, the availability of a conducive learning environment and whether or not taking the workforce out of the service context may be desirable or necessary to address specific development needs and/or to work together with people in different contexts (e.g. cross-fertilisation of ideas and knowledge, disrupting the daily routine to foster new perspectives).

2. Workforce development should be constructed to build on the life skills and experiences that individuals bring to the support worker role, and enable role development and career progression (as appropriate) for the individual and their organisation. This implication is consistent with some of the recommendations from the Shape of Caring review that development should be appropriately aligned with an individual’s skills, experience and ambitions. Some care workers will not have ambitions to progress beyond their current role; others will have different career ambitions. Furthermore, individual care workers contribute to their role based on very different life experiences and skills. Therefore, an individual (and regular) assessment of a person’s skills, experiences and ambitions will enable workforce development to be designed around an individuals’ perspective on these issues.

3. Workforce development should incorporate strategies and techniques that might incentivise and motivate individual engagement in workforce development. These strategies and techniques should be designed to address both extrinsic and intrinsic motivators when possible. It may also be appropriate to make the incentives as relevant as possible to the support worker(s). To sustain motivation, extrinsic motivators should address explicit criteria for attainment, for example rewarding the achievement of specific goals such as attendance at learning events, and changing behaviours and performance.

4. There should be a systematic approach to the design of workforce development which ensures that it is aligned with organisational strategy around, for example, priorities such as quality and integration across health and social care. When this alignment is evident, for example by making explicit transparent links in course content and evaluation with the workforce development initiative and other strategies, such as quality improvement, it should be possible to realise more sustained improvements in workforce knowledge and skills because it should have a cumulative effect.

5. Designing workforce development interventions should include the involvement of the right stakeholders from the beginning of the development process. Stakeholders will probably include relevant agencies, for example organisations/institutions that can provide specialist input and/or educational accreditation/credibility, and individuals, for example support care workers, patients, residents and carers. Co-design processes, including interactive workshops and value clarification activities, will recognise and incorporate the views, expertise and values of each stakeholder constituency.

6. The delivery of workforce development interventions should include opportunities to involve others beyond the support worker him- or herself, for example in shared learning events. There will be learning and development issues, for example improving teamwork, supporting individuals’ transfer of care, what is healthy ageing, dignity in dementia, relationships between staff and families, where it would be relevant and promote resonance and to learn among peers. Involving older people in learning opportunities may be a particularly powerful way to effect changes in value and behaviour, for example regarding antidiscriminatory practice and challenging behaviours. This also links back to the first implication about making learning meaningful and close to the reality of practice.

7. Workforce development design and delivery should be approached in a theory-driven and systematic way. Programme specifications and curriculum plans, for example, should include reference to and inclusion of relevant theory/theories, frameworks and the learning methods/approaches/tools used linked to those underpinning heuristics. In addition, theoretically driven and systematic approaches should be used to evaluate learning and development interventions.

8. Workforce development should be considered a complex programme that is transformative of people and organisations. Therefore, workforce development should not be ad hoc and fragmented. Paying attention to workforce development in the context of the whole system, which includes individuals, teams and the organisation in its wider context, is more likely to result in wider, and potentially more systemic, impacts. This will require joining up and aligning various organisational strategies and associated goals such as human resource management (recruitment, retention, development, exit), organisational development, quality and safety, and resource management.

There are more general implications about support worker development, which were consistently mentioned by professional and lay stakeholders throughout the conduct of the project. These provide a broader context to the delivery of workforce development for this group of care workers:

1. Support workers make up approximately 60% of the health and social care workforce in the UK. 26

2. Professional and lay stakeholders consistently highlighted the importance of investing in the support workforce as a firm foundation on which to improve the quality of health and social care. While recognising the importance of being clinically competent, they also stressed the importance of some fundamental aspects of service delivery, including dignity, compassion and communication. Therefore, workforce development opportunities need to balance the technical with the professional and emotional aspects of caring work with older people.

Related to implication 2, investment in the development of the older persons’ support workforce provides a visible and clear recognition of the value attached to the contribution of support workers. Our evidence identified the use of some incentives to encourage participation with, and engagement in, workforce development. However, there was little evidence of a ‘joined-up’ approach to a workforce development in this context which linked learning with opportunities for career development, personal growth and monetary and other rewards for skill and role development.

Recommendations for future research

Our recommendations for future research relate both to aspects of research methods and to the further evaluation and explication of our programme theory.

With respect to research methods, the synthesis demonstrated generally poor reporting of workforce development interventions. In future research, we recommend that:

• The typology proposed in this synthesis could be used to describe the focus of the intended workforce development.

• Authors provide clear and detailed description of the component(s) of the intervention, including the theory of change for the workforce development intervention being clearly reported. This will make the ongoing synthesis of evidence around workforce development easier to manage and provide opportunities for learning and improvement.

• The complexity of workforce development was highlighted in stakeholder workshops that drew on soft systems thinking, and in the CMO configuration around sustaining the impacts of workforce development across organisations. We recommend that drawing on complexity theory may provide new insights into ‘what works’ in relation to implementing workforce development interventions, and encourage researchers to explore alternative evaluation approaches which reflect different ontological perspectives in the evaluation of workforce development.

The eight CMO configurations resulting from this review provide a programme theory or contingent explanation, grounded in evidence from literature and stakeholder perspectives, about how workforce development works in improving outcomes for support workers, organisations and older people. Research questions relating to the development of the programme theory are as follows:

1. What is the right mix of workforce and organisational related policy to deliver a sustainable support workforce for older people’s services? What are the components of a fully integrated workforce planning and development strategy?

2. How can the sustainability of workforce development be addressed in the challenging context of the older persons’ support workforce?

3. What are the features of a whole-system approach to workforce development operating within a specific geographical context, and which pays attention to social (e.g. characteristics of the service user and workforce populations) and other (e.g. environmental) characteristics?

4. What is the appropriate mix of opportunities for personal and work-related development that balances individual support workers’ engagement in learning with the need to sustain a workforce with the capacity to deliver an effective service?

5. What approaches to the design and delivery of workforce development might be more effective in engaging hard-to-reach groups within the older persons’ support workforce?

6. What are the most effective ways to engage and integrate different stakeholder perspectives, including patient and public representatives, in the design and delivery of workforce development that enables support workers to address the needs older people?

7. What interventions can accelerate support workers’ implementation of gains in knowledge and skill into routine service delivery?

8. What are the best ways of including incentives in workforce development programmes that build on the motivations and aspirations of individual support workers?

Search strategy

S1 TI (advisor* or aide* or assistant* or attendant* or carer* or helper* or mentor* or officer* or paraprofessional* or “peer support*” or practitioner* or staff or technician* or trainer* or worker* or workforce or “care provider”)

S2 TI (“older person” or “older people” or “older adult*” or elder* or “nursing home*” or “residential home*” or “senior citizen*” or gerontology or geriatric* or “aged people” or “aged person*” or aging or senior* or “old person” or “old people” or “old age” or pensioner* or later-life or “later life” or “third age” or retiree* or “long term care” or dementia or stroke)

S3 (MH “Aged+”) OR (MH “Aged, 80 and over”) OR (MH “Health Services for the Aged”)

S4 S2 or S3

S5 S1 AND S4

S6 TI or AB(“accelerated development program*” or “nursing assistant champion*” or “staff support” or accountabilit* or ambassador* or appraisal* or apprenticeship* or barrier* or “behaviour change*” or “behavior change*” or boundar* or “care ambassador scheme*” or career or certification or “change in practice*” or “clinical education program*” or communication or coaching or credit* or “decision support” or delegation or develop* or education or e-learning or “emotional support” or “expectation* of staff” or framework* or governance or incentive* or induction* or information or “job specification*” or knowledge or leadership or learning or “learning technolog*” or network* or nurse-led or “organi?ational change*” or “organi?ational context*” or “organi?ational culture*” or “organi?ational improvement*” or “organi?ational value*” or “orientation program*” or “performance management” or “person centred” or “person centered” or planning or polic* or practice* or “practice change*” or “practice centred approach*” or “professional development” or “protected time” or qualification* or registration or regulation* or relationship* or responsibilit* or reward* or role* or service or simulation or skill* or “staff development” or storytelling or strateg* or supervision or team* or training or well-being or wellbeing or “well being” or “workforce development”)

S7 (MH “Communication+”) or (MH “Delegation, Professional”) or (MH “Clinical Governance”) or (MH “Access to Information+”) or (MH “Knowledge”) or (MH “Leadership”) or (MH “Organizational Objectives”) or (MH “Organizational Innovation”) or (MH “Organizational Culture”) or (MH “Policy Making+”) or (MH “Peer Review+”) or (MH “Professional-Patient Relations+”) or (MH “Interprofessional Relations+”) or (MH “Personnel Management+”) or (MH “Patient Care Team+”) or (MH “Credentialing+”) or (MH “Professional Role+”) or (MH “Clinical Competence”) or (MH “Staff Development”)

S8 S6 or S7

S9 S5 and S8

S10 restricted 1986-to date