Care practices and incontinence-related stigma for formal carers of people living with a dementia in a care home setting: a qualitative study

Abstract

Formal care workers in residential dementia care settings can be considered “dirty” workers, contaminated by the taints and stains of continence care, servility, and perceived moral ambiguity. This can have a significant impact on the maintenance and development of a positive social identity, particularly when this translates into societal devaluation and the “low status” of the care worker role. As social care organisations struggle to maintain and recruit care staff it is increasingly important to understand the lived experiences of care workers.

Using theories of stigma and dirty work, this thesis reports on a qualitative study which
investigated how care staff in the UK mitigate or reproduce continence related stigma in care homes, and explores the care practices that aid care staff in this. Semi structured
interviews were conducted with care staff to explore their experiences and rationalisation of continence care. Document analysis of guidelines, frameworks and Care Quality Commission (CQC) reports was conducted to establish organisational factors that may influence these experiences.

Three themes arose from the study: (1) Responses to continence and incontinence demonstrated that observations related to continence care were used by external organisations and others as an indicator of care quality, while care workers’ experiences reflected a lack of training and preparation. (2) The need for community evidenced that participants sought to mitigate perceived societal devaluation by forming a community of peers that reinforced shared values and positive social identity. (3) The final theme, group boundaries, established that participants reframed continence care and contact with faeces as a “rite of legitimacy” that demarcated the boundaries of the group and accredited their skillset within the “dirty worker” role. Participants judged others on this accreditation, and actively expelled those who did not successfully pass the rite. Lack of
contact with faeces indicated a lack of appreciation, understanding, or consideration of the intricacies of the care worker role. Training and knowledge that come from external organisations or individuals not accredited in this particular way was disregarded or actively ignored.

By understanding the rite of legitimacy, researchers can begin to understand how care workers rationalise their experiences to maintain positive social identities. Additionally, researchers and practitioners can learn to plan more effective interventions to improve dementia care. Interventions such as training programmes require the support and participation of the care workers involved. This may be more easily achieved by someone who has attained accredited status in the care worker community.

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Identifiers

ORCID for Leah Fullegar: orcid.org/0000-0002-1714-564X

ORCID for Jackie Bridges: orcid.org/0000-0001-6776-736X

ORCID for Ruth Bartlett: orcid.org/0000-0002-3412-2300

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