The Social Construction of Stigma in Aged-Care Work: Implications for Health Professionals' Work Intentions

Challenging aged care stigma through communication: discursive responses to stigmatising discourses about aged care work and implications for workers' mental health

Occupational stigma can negatively impact aged care workers' (ACWs) mental health. This mixed-methods study investigates whether ACWs who challenge stigmatising discourses, through communication, experience reduced psychological costs of aged care stigma. We screened 184 ACWs' discursive responses and tested for differences in ACWs' mental health between those who challenge stigma and those who do not. A discourse approach was further employed to examine recurring language patterns in 'challenge' discursive responses. ACWs (n = 95) who discursively challenged stigmatising discourses reported lower internalised occupational stigma and psychological distress than those who did not challenge stigma (n = 89). These workers chose to infuse positive value into negative evaluations about ACWs and aged care work. Overall, findings suggest that ACWs may spontaneously challenge occupational stigma, through their discursive responses, which may proactively protect their mental health. We offer practical implications for challenging stigma, including developing guidelines, training, and language-based interventions.

Understanding factors influencing personal care workers' intentions to stay: A systematic integrative review

OBJECTIVE

To systematically synthesise existing literature to identify influences on personal care workers' intentions to stay when employed in residential aged care.

METHODS

A systematic integrative review was conducted, searching relevant literature across multiple databases, including Business Source Complete, CINAHL Complete, Medline Complete and APA PsycInfo via the EBSCOhost platform and EMBASE (excluding Medline). Articles were eligible for inclusion if they were peer-reviewed, published in English between 1997 and 2024, and focused on factors influencing personal care workers' intentions to stay in residential aged care. The methodological quality of the selected articles was assessed using the Mixed Methods Appraisal Tool.

RESULTS

This review included six articles published between 2007 and 2021, reporting on quantitative (n = 4), qualitative (n = 1) and mixed methods (n = 1) research, with the final study published in 2021. Five employee-related and employer-related themes emerged as important factors that influence personal care workers' intentions to stay: (1) individual characteristics and resilience, (2) career growth and rewards, (3) employment stability and economic workforce pressures, (4) satisfaction and fulfilment in professional caregiving and (5) organisational support and collaborative work environment.

CONCLUSIONS

This review identified key factors influencing personal care workers' intentions to stay, offering actionable insights to inform the development of evidence-based strategies aimed at strengthening workforce retention. Addressing these factors is critical to meeting the needs of an ageing population and ensuring the provision of high-quality care. Furthermore, the review underscores the multifaceted determinants shaping these intentions, emphasising the importance of psychological, social and organisational factors to enhance retention efforts.

The importance, challenges, and proposed solutions for preceptors to educate the nursing workforce

Preceptors are essential in the clinical education of prelicensure registered nursing and advanced practice registered nursing students. However, there is a growing scarcity of preceptors available to provide clinical education. Additionally, preceptors have not uniformly received professional development in the practice of teaching that is essential in delivering high quality clinical education, and clinical education in nursing is an unfunded mandate. This article reviews the current state of preceptors, the importance and challenges of preceptors in clinical education, the lack of funding for clinical education by preceptors, and proposed solutions.

Barriers and facilitators to implementing person-centred dementia care in long-term care facilities in Western and Asian countries: a scoping review

Background

There is a gap between the principles of person-centred dementia care and their actual implementation. However, scoping reviews of the barriers and facilitators to implementing person-centred dementia care in long-term care facilities for Western countries and Asian countries are lacking.

Objective

To identify and compare the barriers and facilitators to implementing person-centred dementia care in long-term care facilities between Western and Asian countries.

Methods

In line with Arksey and O'Malley's methodology, a scoping review was conducted and is reported following PRISMA-ScR guidelines. Nine English language databases and three Chinese databases were searched to identify qualitative and quantitative research studies published in English and Chinese. Thematic analysis was used to summarise and characterize the barriers and facilitators to implementing person-centred dementia care in long-term care facilities for Western and Asian countries.

Results

Thirty-three studies were included. Over half were conducted in Western countries (n =20). Barriers and facilitators were grouped under four high level themes: Nursing and care staff factors, people living with dementia and family factors, organizational factors, and resource factors. Inadequate knowledge of person-centred care, staffing shortages, time constraints, and low wages were the principal barriers to implementing person-centred dementia care in both Western and Asian countries.

Conclusions

The findings indicate that staff encounter numerous obstacles and needs in implementing person-centred care for people living with dementia in long-term care settings. Educational levels of nursing staff in Western countries were generally higher compared to Asian countries. Additionally, work-related injuries and stigma associated with dementia care presented unique challenges for nursing staff in Asia and were not cited in Western studies. Conversely, family-related factors were more frequently and elaborately cited as influencing person-centred dementia care in Western long-term care facilities. Moreover, Asian studies identified a significant lack of educational training support for person-centred dementia care, as well as shortages in staffing and poor availability of personalized, home-like environments.

Shifting Student Attitudes of Gerontology Nursing: A Quasi-Experimental Evaluation of a Clinical Educator Programme

BACKGROUND

Enduring shortages in the gerontology nursing workforce are projected to increase as demand for services for older persons grows. Recruitment of Registered Nurses in gerontology is further hindered by negative perceptions held by students towards nursing older people.

AIM

To determine whether a professional development activity designed to assist clinical supervisors to build the mentorship capacity of care staff in residential aged care facilities could positively improve their clinical learning environment and improve student attitudes towards working with older adults.

DESIGN

A quasi-experimental, non-equivalent pretest-posttest control group design.

SETTINGS

Clinical settings in which participants were undertaking an older person-focused clinical placement.

PARTICIPANTS

A purposive sample of 466 first-year undergraduate nursing students. Forty-seven students responded to both the pre- and post-placement surveys.

METHODS

The intervention comprised four professional development sessions delivered to clinical supervisors supervising nursing students during clinical placement across three residential aged care facilities. Pre- and post-placement surveys measured Student Perceptions of Working with Older People (SPWOP). The modified Clinical Learning Environment Inventory (CLEI) was included in the post-placement survey to measure student perceptions of the clinical placement learning environment.

RESULTS

Control group participants reported higher pre-placement SPWOP scores yet showed no significant improvement in score post-placement; however, the intervention group reported a statistically significant increase in SPWOP score post-placement. Modified CLEI results revealed the control group reported higher levels of engagement in the learning environment, yet the intervention group reported greater motivation to learn.

CONCLUSIONS

An intervention designed to build staff mentorship capacity in gerontology care settings can positively influence student perceptions of working in gerontology. Despite these positive gains, results indicated that students who undertook placement at the intervention sites were less engaged. This disparity illuminates the need for continued efforts to build staff mentorship capacity in older person-focused clinical learning environments to improve student experiences and perceptions of gerontology nursing.

IMPLICATIONS FOR PRACTICE

Further research that engages directly with unregulated healthcare workers in geronotological care settings could provide new insights into what this cohort need to become effective mentors and shift student nurse attitudes towards caring for older adults.

How Do Home Care Workers Experience A Client's Death, Professionally and Personally? A Systematic Review and Meta-Synthesis

Background: Home care workers (HCWs) may frequently experience client death. This critical interpretive meta-synthesis aimed to identify the impacts of client death to offer preliminary recommendations with respect to support. Method: Five electronic databases, APA PsycINFO, CINAHL, MEDLINE, Web of Science, and Scopus, were searched systematically using keywords and subject headings. Results: Eight papers focusing on HCWs' experiences of client death were identified. Constructs were elicited and interpreted via Reciprocal Translation Analysis. The interpreted line of argument highlighted four interrelated themes: ''Personal grief: The impact of loss', 'Disenfranchised grief: no space for humanity and connection'', Inherent tension between self-care and organisational expectations: "You need a moment to hit the reset", and 'I wish someone was there to talk to: HCW support needs'. Conclusions: The findings demonstrate that HCWs are affected in multiple ways by client death, but these impacts are not consistently recognised or responded to by their organisations.

Understanding the experience of stigma in care homes: A qualitative case study in northeast Thailand

WHAT IS KNOWN ON THE SUBJECT?: Stigma associated with care homes has been found to influence residents' lives, and it is a known risk factor for depression among older adults worldwide. Older residents in Asia and particularly, in Thai care homes commonly experience stigma due to being strongly influenced by a traditional cultural paradigm of filial piety. The understanding of how residents perceive and experience the stigma associated with residing in care homes, as well as its link to the development of depression, remains very limited. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: This research explains the dynamics of the process of the stigma associated with living care homes among Thai older residents. This research highlights the various ways in which stigma impacts residents, their families and care home staff. This study identifies mitigating stigma factors, including social support, coping strategies (karma, mindfulness and religious devotions) and activities that may mitigate perceived stigma associated with care home residency. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is a compelling need to improve the well-being of older people living in care homes and to combat the cultural stigma associated with living in care homes through promoting positive attitudes and educational interventions in society, communities and care homes themselves and involving residents' families in the planning and delivery of care for residents. We advocate that the government promotes security and sustainable life for all Thai older adults.

ABSTRACT

INTRODUCTION: Stigma associated with living in care homes is a known risk factor for depression among care home residents in Asia, including Thailand. However, little is understood about how such stigma is experienced among residents and care home staff.

AIMS

To examine older adults' perceptions of stigma and to understand how stigma associated with living in care homes causes or exacerbates depressive symptoms.

METHODS

A qualitative case study approach was used to gain an in-depth view of stigma, from two public care homes in northeast Thailand. Data were collected by in-depth interviews with 50 participants (30 older residents and 20 care home staff), and non-participant observation was conducted over 1 month. Thematic analysis was used to analyse the data.

RESULTS

The study identified three major themes of stigma, comprising the causes of stigma, reactions toward stigma, and mitigating factors.

DISCUSSION

Negative beliefs about care homes and residents, contribute to stigma. Residents exhibited negative emotions and behaviours, including depressive symptoms. Residents reported using particular coping strategies that helped them cope with their perceptions of stigma.

IMPLICATIONS FOR PRACTICE

Future research should focus on strategies or research to combat stigma in order to prevent depression and reduce perceptions of stigma.

Discriminative and exploitive stereotypes: Artificial intelligence generated images of aged care nurses and the impacts on recruitment and retention

This article uses critical discourse analysis to investigate artificial intelligence (AI) generated images of aged care nurses and considers how perspectives and perceptions impact upon the recruitment and retention of nurses. The article demonstrates a recontextualization of aged care nursing, giving rise to hidden ideologies including harmful stereotypes which allow for discrimination and exploitation. It is argued that this may imply that nurses require fewer clinical skills in aged care, diminishing the value of working in this area. AI relies on existing data sets, and thus represent existing stereotypes and biases. The discourse analysis has highlighted key issues which may further impact upon nursing recruitment and retention, and advocates for stronger ethical consideration, including the use of experts in data validation, for the way that aged care services and nurses are depicted and thus valued.

The development and validation of tour guides internalized occupational stigma scale (TIOSS)

BACKGROUND

Tour guides' identification and internalization of occupational stigma may exacerbate their career development, perceived professional reputation and status, and mental health. The current study aimed to develop and verify the Tour guides Internalized Occupational Stigma Scale (TIOSS) to provide an effective tool for relevant quantitative research.

METHODS

The study developed an initial questionnaire through literature analysis, expert review, and semi-structured surveys. We conducted item analyses and exploratory factor analyses among 326 tour guides, and confirmatory factor analysis and reliability and validity tests among 315 tour guides.

RESULTS

The TIOSS consists of 21 items and is formed in three dimensions referring to Stigma Perception (SP), Status Loss (SL), and Career Denial (CD). The correlation coefficient values of the TIOSS total scale and dimension scores with the criterion instruments ranged from 0.17 to 0.68. In addition, the Cronbach's α coefficients for the TIOSS and its dimensions ranged from 0.837 to 0.928, and the split-half reliability coefficients ranged from 0.843 to 0.916. The study also revealed that the TIOSS was consistent across genders.

CONCLUSION

The TIOSS performed favorable reliability and validity to be a valid instrument to assess tour guides' internalized occupational stigma.

Exploring a career pathway for home support workers in Ireland: a systematic scoping review of the international evidence

Background

In prosperous nations like Ireland, home support workers (HSWs) play an increasingly vital role in providing person-centred care to ageing populations. However, challenges such as workforce shortages, role ambiguity, low pay, and limited career advancement, hinder workforce development and career building.

Method

A scoping review using key terms for "HSWs" and "career pathways" was conducted following the Joanna Briggs Institute Methodology, examining electronic databases (Web of Science, PubMed, MEDLINE, EMBASE, CINAHL, PscyINFO, Social Care Online, Social Sciences Citation Index). Inclusion criteria were applied, and a thematic analysis followed and inductive-deductive approach.

Results

The review encompassed 261 relevant articles from different countries. Four key themes were identified: (1) Data-driven decision-making on the future workforce, (2) Attracting and developing a competent and motivated home support workforce, (3) Enhancing working lives and retention at every stage of career pathways, and (4) Crafting career pathways to improve quality and impact.

Discussion

Leadership, collaboration, and data-driven decision-making across policy, research and practice are pivotal for expanding and enhancing home support. Emphasising a shift towards preventative self-management models, supported by digitally skilled and regulated HSWs, could enhance independence and quality of care. Clear career structures, professional development, and inclusive organisational environments are essential to attract, retain, and empower a competent and motivated workforce, fostering quality and impact.

Conclusion

This scoping review provides foundational evidence to establish career pathways for HSWs, identifying key areas for development such as data collection, care model transformation, career progression structures, and systems for safety and quality improvement.

Occupational stigma consciousness and professional commitment among Chinese nursing students: Path analysis of survey data

Pervasive stigma exists around nursing in Chinese society and can affect nursing students' commitment to the profession. Based on the resource conservation theory, this study aimed to investigate the relationship between occupational stigma consciousness and psychological empowerment in nursing students' professional commitment in China. Data were collected from November 2021 to May 2022, and 1189 nursing students participated in the study. Occupational stigma consciousness, professional commitment, and psychological empowerment were assessed using a questionnaire. The path analysis indicated that occupational stigma consciousness negatively predicted professional commitment (β = -0.127, p < 0.001) and psychological empowerment (β = -0.329, p < 0.001), and psychological empowerment mediated the relationship between occupational stigma consciousness and professional commitment. To resist occupational stigma consciousness and improve nursing students' professional commitment, nursing policies and education should focus on improving psychological empowerment.

"The Stigma is what you do": Examining the Relationship Between Occupational Stigma and Worker Outcomes in the Aged Care Context

Negative social evaluations about aged-care work continue to discredit those who perform this type of work. Drawing on 'dirty work' literature from the field of management and stigma theory from the field of psychology, this study examines occupational stigma in the context of aged-care work and its relationship with negative outcomes for people who work in aged care. Findings from a path analysis revealed that aged-care workers (n = 185) who ascribe occupational taints and poor occupational conditions with aged-care work perceive aged-care work as being stigmatized, and in turn, are more likely to internalize this stigma. Through this process of perceiving and internalizing occupational stigma, aged-care workers experience greater psychological distress, job dissatisfaction, and turnover intentions. This research fills a void within the gerontology literature regarding the psychological processes underlying how occupational stigma may come to negatively impact this workforce. Findings offer practical implications for policy reform and managerial training.

Development of the Chinese Version of the Physician Internalized Occupational Stigma Scale (PIOSS)

BACKGROUND/OBJECTIVE

Internalized occupational stigma may develop in physicians as a result of their identification with the public negative labels and stereotypes about them, and then internalization of them as a part of their self-concept. This study aims to develop the Physician Internalized Occupational Stigma Scale (PIOSS) and to examine its reliability and validity.

METHODS

In study 1, the initial scale was used to investigate 356 physicians. While in study 2, a total of 346 physicians were investigated with the survey tools named the PIOSS, the Career Commitment Scale (CCS), the Workplace Well-Being Scale (WWBS), the Scale for the Doctor with Patient-doctor Relationship (DDPRQ-10), the Intent to Leave Scale (ILS) and the Occupational Disidentification Scale (ODS).

RESULTS

The PIOSS includes 19 items divided into 3 dimensions: label identification, status loss, and career denial. The results of confirmatory factor analysis (CFA) reveal that the three-factor model fitted well (χ 2/df=2.574, RMSEA= 0.068, CFI= 0.931, IFI= 0.931, TLI= 0.919, PNFI= 0.762, PCFI= 0.795). The PIOSS total and each dimension scores were significantly negatively correlated with the CCS and the WWBS scores and remarkably positively associated with the DDPRQ-10, the ILS, and the ODS scores. Cronbach's α coefficients for the PIOSS total scale and dimensions ranged from 0.775 to 0.914, and split-half reliability coefficients ranged from 0.801 to 0.931. In addition, the PIOSS exhibited cross-gender invariance.

CONCLUSION

Having good reliability and validity, the PIOSS can serve as a valid tool for the assessment of physician internalized occupational stigma.

Patient Toward Physician Occupational Stigma Scale: Development of the Chinese Version

BACKGROUND/OBJECTIVE

Physicians' occupational stigma could eradicate physician-patient trust, threatening physicians' social status and occupational reputation. Hitherto, there has been no scale obtaining good psychometric properties to assess patients' stigma toward physicians. The present study aimed to develop the Patient toward Physician Occupational Stigma Scale (PPOSS) and examine its reliability and validity.

METHODS

The questionnaire comprising sociodemographic information and the PPOSS were employed to survey 645 Chinese patients in two phases. In Sample 2, the Wake Forest Physician Trust Scale (WFOTS), the Intolerance of Uncertainty Scale-12 (IUS-12), and the Brief Illness Perception Questionnaire (BIPQ) were tested.

RESULTS

The PPOSS includes 19 items subsumed into three dimensions of stereotype, discrimination, and prejudice. According to the results of confirmatory factor analysis (CFA), the three-factor model fitted well (χ2/df=2.065, RMSEA=0.057, SRMR=0.045, RFI=0.904, CFI=0.956, IFI=0.956, PNFI=0.779, PCFI=0.811). The PPOSS was significantly negatively correlated with the WFOTS, and significantly positively correlated with the IUS-12 and the BIPQ. The Cronbach's alpha coefficients for the total scale and each dimension were between 0.87 and 0.94, and the split-half reliability coefficients were between 0.84 and 0.93. Besides, the PPOSS had the measurement invariance across gender.

CONCLUSION

With its satisfactory psychometric properties, the PPOSS can be used as an effective instrument to assess patients' stigma toward physicians.

Combining ethnography and conversation analysis to explore interaction in dementia care settings

Background

It is well established that the actions and behaviour of care home workers are fundamental to the well‐being of the people they care for. They not only deliver basic care but through their day‐to‐day presence provide an underlying continuity for residents, many of whom will have dementia or other cognitive problems. This can have many positive psychological and social benefits. A variety of ethnographic approaches have been used to explore the broader social and cultural dimensions of dementia care work. Similarly, there is a growing body of work applying micro‐level approaches such as conversation analysis (CA) to describe the interactional mechanics of specific care skills.

Strategy

We outline what ethnography and CA are, how they work as stand‐alone methodologies and how they have been used in care work and dementia care settings. A working illustration is given of how the two approaches may be integrated.

Discussion

Dementia care workers occupy a uniquely tenuous sociopolitical and professional position within healthcare. If they are to progress to a more professional status there is a pressing need for standardized systems of training to be developed. As has been common practice in most other fully professionalized sectors of healthcare, this training needs to be backed up by an understanding of how effective care work is undertaken at the micro‐level. For it to be practically relevant to care workers it also needs to have been informed by the wider social context in which it occurs.

Conclusion

We argue that elements of ethnography and CA can be usefully combined to provide the fully contextualized micro‐level descriptions of care work practice that will be needed if current moves towards the greater professionalization of care work are to continue.

Patient or Public Contribution

The authors undertake a significant amount of Patient and Public Involvement and Engagement and study codesign with members of the public, care workers and people living with dementia. Our engagement work with care staff and family carers undertaken as part of a current National Institute for Health Research study exploring naturalistic care worker skills (see acknowledgements) has been particularly relevant in shaping this article.