Conflict in care settings

People usually go into care work because they care. The nursing and social care students, trained staff and managers we meet, express their genuine desire to make a positive difference in the lives of people who use care services.

There are many fantastic staff who save lives and boost spirits on a daily basis. People use care services because they have nursing or daily life or mental health needs. Some people need a safe place to stay.  They may be vulnerable to drink or addictions, to abuse, to falls, or neglect, to self-harm, to causing harm, to poor mental health, or physical deterioration and a wide range of other issues, which necessitate compassionate support.

So how does it go wrong in care settings?

I think there are several contributory factors to abuse within our care systems and social structures. Blaming and distancing ourselves from the issues is not helpful. Violence and aggression threaten our well-being, dignity, confidence, and lives. We have probably all experienced moments of feeling sheer anger and aggression. We need to understand how that happens in carers…. not to justify it, for there is no justification… but to ensure the systems, people and practices improve.

Our care organisations operate beneath an umbrella of important legislative policy, procedures and standards. Organisational culture consists of people’s habits, beliefs, values and rules. At a very basic level, these elements create closed or open cultures. Closed cultures tend to be institutionalised and oppressive. Abuse can hide more easily where individuals do not recognise their freedom to speak out. We all want more open cultures, where people can voice concerns and fears; where complaints are regarded as messages of hope for change; and where time and opportunities are given to discuss complex issues.

What really makes an organisation is the people; from the care and support staff to the managers and CEOs. The standards of care depend on their values, rules, knowledge, skills, awareness and understanding. Staff do what they learn how to do within their perceived roles. This is influenced by their experiences, by how they are treated, their individual capacity for learning, clarity of responsibilities; their personal values, and their mental health.

Sometimes the carers’ personal beliefs get in the way of working in an inclusive, person-centred way. They might struggle to see how someone with late stage dementia could be included in anything. This leads to more isolation and can easily slide into neglect.  But supported reflective practice and learning can help staff see possibilities and improve quality of life.

Occasionally a significantly damaged and damaging individual slips through the selection and recruitment process. Whilst the majority of staff go into care work to care, occasionally there are people who are attracted to the work because they are personally in need of care. Somehow they miss the regular support systems all the way through life, and come in to the system as a worker. Some wounded healers are actually very good carers. But others are clearly not. Add to this an environment or culture that does not offer regular supervision, nor pick up signs of disturbance through mentoring, or observations, and we have trouble.

Burnout or carer fatigue is a big sign to take notice of.  Emotional, physical and mental exhaustion is caused by long periods of stress. This affects people in different ways. Some people may be present in body, but emotionally shut down and seem to lose the ability to connect on a humane level. Other people become hypersensitive to the suffering they see around them. They feel helpless and are in constant emotional pain. Either way requires intervention, support, and change.

Many people go in to care work with good intentions. The core care values about dignity, respect, rights and choices, effective communication, promoting self-worth, improving inclusion, honouring privacy and protecting people from harm, resonate deeply with them.

I’ve met carers who discovered these purported values could not easily be promoted within the care systems. When staffing levels are short or a regimented routine is in place, the staff do their best to keep delivering from the core values. But something happens to people when their personal values (those care values that meant so much to them), are constantly hindered by the environment in which they work.

There is an internal conflict. The gap between what they want to do, and what they feel they actually can do becomes increasingly difficult to deal with. It is at this point of stress that things happen. Staff might decide to leave and find a place that walks its talk, where they can deliver the good practice they believe in.  Or they may become ill and go off sick, or become emotionally distant. Or they become increasingly frustrated and angry. Bullying in the care sector is known about.

Managers and team leaders need to be equipped to deal with signs of staff burnout, to deliver regular supportive supervision, and understand how to motivate and inspire their staff. They need to listen to what is happening and be willing to question their own practice, values and rules to see how to operate in more person-centred ways. And to do this with their staff, and with the people using their services, and with all the organisations who can help them.

It is of no surprise that staff who feel confident, happy, valued and appreciated deliver good services. Staff who are undervalued, unappreciated, underpaid, and lacking in confidence can also deliver great services, but at a high cost to themselves. We owe it to everyone using care services to support staff to do their work well.

This article is an extract from my writings (copyright KMarshall2011) Please share

Help and advice:

The first point of contact to raise concerns about the working practice is with your line manager.

These organisations offer further help and advice

Whistleblowing for NHS staff and social care staff: 08000 724 725    Contact the helpline if you have concerns but are unsure how to raise them or simply want advice on best practice

Care inspectorate (Scotland)  Download a leaflet about how to make a complaint  Complaint about a care service us on 0845 600 9527    Also read the national care standards

Care Quality Commission (England)   Download a booklet about how to make a complaint:  Customer service number: Telephone: 03000 61616    Also read the standards of care

Bullying and harassment help: ACAS (put bullying and harassment in their search box)

There are many other help and advice organisations on line. Go well.



  1. Great points. I worked as a care assistant for a number of years before training as a social worker and I can recognise some of what you write about. While pay is one factor which indicates the way staff are valued (or not) there is a lot to be said about the cultures of care which exist in particular settings.
    Bullied staff who are treated poorly are less likely to be able to reflect that empathy on to others – and while there will always be some people who are drawn to care settings because they are able to express power issues that are lacking in their ‘out of work’ lives, the best way of rooting this out is through good management/supervision.

    Meanwhile the differentials in the way residential settings are regarded across age cycles must be challenged. We place older people in large nursing/residential homes of 50+ (have come across 100+) bed units when we were supposed to be promoting deinstitutionalisation – this doesn’t count in dementia care as the money and desire for change hasn’t reached commissioning in local authorities.
    Inherent ageism in the structures of care has to be challenged too.

    • karrie says:

      Thanks so much for your responses. Yes, we often see parallel processing (staff treating clients in the way they have been treated by managers) … constructive, supportive supervision and self-reflective practice are important for quality care.

      On the subject of ageism…structural ageism seems like the elephant… so big that people don’t see it, yet they bump into it all the time. We are meeting more people who have had enough of the generations of cultural messages about what aging people can and cannot do; and the types of settings they are expected to live in. Mindsets are shifting. It is going to be interesting to see how so many of our care structures, which currently limit choices and opportunities for older people, are going to transform. We all have a role in the process… from keeping ourselves as fit and healthy as possible, through to finding ways to deliver genuine person-centred care. with best wishes to all..

  2. Very good article. You are right to the point. I agree about providing the supported environment for Carers, including regular supervision and learning and development opportunities.

    Thanks and kind regards

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