The Material Citizenship™ training programme

The Material Citizenship™ training programme was co-produced in 2020 with staff from one of the participating care homes. The training approach was based on David Klob’s four-step Experiential Learning Cycle (McCarthy, 2016). This utilised staff experiences in the training room and gave staff opportunities to reflect on the practices in their own care home. All staff were invited to attend, regardless of their job title.

The training was delivered through an online platform (due to COVID-19 restrictions), over two half-day sessions set four weeks apart. The first session introduced participants to the concept of Material Citizenship™ using videos, group work, and individual activities. For example, participants were asked to think about the functional objects that were important to them, which ones they would need to have in everyday life, how they would feel without them, and what their feelings/behaviour might look like if these objects were absent. This enabled staff to walk in their residents’ shoes. In addition, participants were given scenarios describing ‘residents’ acting in a certain way. They were asked to discuss what they thought was going on for the person and how they might apply Material Citizenship™ in such a case. To end the session, participants were invited to apply the approach in their own workplace and to report back at the second session.

The second session explored participants’ experiences of implementing Material Citizenship™, including what had or had not worked well. Staff explored how to document evidence of Material Citizenship™ and its impact in care records, and how information could be shared both internally and externally with other staff members, external health organisations, and regulators.

Data collection

This is a qualitative evaluation of the Material Citizenship™ training programme across four care homes. All staff (n = 41) who participated in the training were invited to take part in a semi-structured interview. The interview was conducted via Microsoft Teams, and those who agreed provided written consent in advance. Interviews took place within three months of the training (between May and August 2021). The interviews were audio recorded and transcribed. Interviews ranged from between 20 and 46 minutes (range 35 minutes) long.

Analysis

Data analysis was both deductive and inductive, informed by the aims of the evaluation, but also allowing for the participant voice. A thematic analysis approach was taken (Braun and Clarke, 2006). The researcher (JF) first familiarised themselves with the data and undertook open coding. Data within codes were used to describe and summarise the topics of interest: reactions to the training, impact of the training on care delivery, and implementation challenges. Code summaries and interpretations were discussed with the other authors in data meetings.

Ethics

The study received ethical approval from the University of Southampton Ethics Committee (reference 54289).

Sample and setting

A total of 23 interviews were conducted and analysed. Twenty-one of the respondents were female. The sample included all three staff role types involved in the training (see Table 1).

Reaction to the training programme

Responses to the training were positive, with staff finding it enjoyable, interesting, easy to understand, and useful. Interactive activities were most favoured, being valued for sharing ideas and ease of engagement. Several participants appreciated the use of real rather than simulated case studies, thus relating directly to their own practice. These interactive activities were thought-provoking, helped participants to empathise with residents and prompted reflection of current practice, which it was felt could be more person-centred.

I think it made us realise that actually we sometimes do that [take objects away from residents] without even realising we’re doing it, particularly in day-to-day care work, and I think it made us all think about we really need to pay a lot of attention to this, it’s not just a small thing, it’s massive and can have a massive impact on somebody’s emotional well-being. (Interview 16, Lead)

Other, less interactive aspects of training were not so readily recalled by participants. However, several mentioned the value of the animated video for understanding in advance what the training was about, with potential use to promote understanding within their networks, for instance with the wider team, care home management, family members, and wider society. While some felt they would have preferred face-to-face training, all felt that online training was acceptable.

Understanding of and confidence to deliver Material Citizenship™

Participants’ understanding of Material Citizenship™ was most commonly described as supporting residents to do what they used to do, as well as recognising resident’s preferences, and making an experience from an object.

It’s about people being able to use their own personal items and normal everyday household items as if they were living at home, still being fully independent, and what that means to them as people. (Interview 23, Lead)

Participants perceived several benefits of a Material Citizenship™ approach for residents, including increased independence and control, comfort, reassurance and well-being, and evoking positive memories of the past. These benefits were recognised as sometimes helpful in evading ‘challenging behaviours’. Material Citizenship™ was also considered helpful for facilitating the move into the care home, through familiar objects that residents bring with them. Several participants recognised the role of Material Citizenship™ in maintaining resident’s identity.

It’s about material things, ownership of things. Your things that are you, that describe you as a person. It’s how material objects can define you, and how important they are for you to maintain your identity, and to perform everyday tasks. (Interview 23, Lead)

There were also perceived benefits reported for staff, some participants describing how they found implementation of Material Citizenship™ to be rewarding, leading to added motivation and job satisfaction.

It makes me want to come to work, it makes me want to motivate the team, it makes me want to look at how we can make our residents’ life full. (Interview 25, Manager)

For some, this was a new way to think about implementing care, whereas others felt they were already applying Material Citizenship™ in their care. For the latter, the training was still helpful in providing a full understanding of the importance of functional objects, and in prompting staff at all levels to be more mindful of the importance of functional objects within care. Staff from two sites felt the training was confirmatory of their practice, it had reinforced that what they were doing was right and over and above standard approaches. Participants also felt Material Citizenship™ could support them in delivering outstanding care.

It helps me focus more on the individual, it helps be less risk-averse, it can help create a really nice enabling environment, rather than a disabling environment, gosh, all sorts of reasons, yeah, and not just outstanding from a compliance perspective, I think … from the resident’s perspective, you know, if I was experiencing outstanding care, I would want to be doing the things that I love to do, you know, that’s for me what makes outstanding care. (Interview 16, Manager)

Some staff reported feeling more confident to challenge colleagues in their practice, to talk to family members about the importance of functional objects and to justify their approach to review bodies. This was, in part, related to having an evidence base to draw from which helped staff to articulate the importance of objects in quality of life.

I think it makes it a lot easier for me to put across to other people that maybe don’t think like that [about functional objects], because I have like a proven backup thing to say, ‘Well look!’ If it’s just your thoughts, someone can go, ‘Oh whatever’ but if it’s like a proven thing, and a study, and something that’s proved to work, I think it’s a lot easier to tell other people about it. (Interview 3, Carer)

Implementation of Material Citizenship™ in practice

There were many reported examples of Material Citizenship™ being implemented in the participating care homes, incidents of thoughtful inclusion of functional objects in the everyday lives of residents. These are categorised here as examples of facilitation of: involvement in activities of daily living; hobbies and interests; choice in aspects of care; the transition into the care home as well as recognising and maintaining routines; and including functional objects in care planning.

There appeared to be differences across the sites in the number and type of examples of care being influenced by Material Citizenship™. In particular, Site Two gave fewer examples of Material Citizenship™ in practice, and no examples of facilitation of interests and desires. However, only two interviews were conducted at this site, so it is difficult to draw conclusions about the extent of implementation here.

Participants at Sites 1, 3, and 4 described how they facilitated the involvement of residents in daily chores, such as washing up and laying tables. This was sometimes because they knew residents enjoyed this activity but was also used as a distraction when residents were agitated.

Now just doing this training I wouldn’t even think twice, like now after lunch, get the gloves out, she starts washing everything up, and again, straight away that’s like half an hour’s gone and her mood’s a lot more positive, she feels like she’s done something (Interview 31, Carer)

Several participants (Sites 1, 2, and 3) also talked about facilitating the choice of objects within activities of daily living. This included allowing choice in using a wheelchair or frame, encouragement to choose a preferred health/beauty product, choice to leave a room in an untidy state, and choice to shave despite concern about possible skin issues.

There were several examples (Sites 1, 3, and 4) of facilitating the hobbies and interests of residents. This included encouragement for interested residents to get involved with activities happening around the home, such as gardening, painting and crosswords, but also the initiation of a resident’s preferred activity. For example, staff from one home were planning to encourage a woman with dementia to re-engage with photography, with a view to inviting people to an exhibition of her work; another facilitated someone with a keen interest in football to have a kickabout; at a third care home, a hospitality manager purchased Alexa devices so that residents could request the music they wanted to listen to.

We want to start encouraging her, to reintroduce her to the camera so she can take photos. She’s got a printer in her room to print her own pictures. So that’s something which we know, it was really meaningful to her, she’s done a photography course in the past… So, we want to encourage her to do activities more, using the camera. With a look to do her own little photography exhibition. (Interview 23, Lead)

Several participants (Sites 1, 2 and 3) relayed how Material Citizenship™ training had helped them to recognise and maintain residents’ routines.

I found instead of coming out in the afternoon and sitting with other residents, she [the carer’s resident] likes to go back to her bedroom, sit in her armchair and she likes to have Classic FM on her radio and then she will just be relaxed. (Interview 19, Carer)

There was one example (Site 3) of a focus on functional objects within a care planning process. A conversation with a resident led to a plan detailing what functional objects were needed and how they should be used. The participant likens the process to a prescription, for well-being rather than for medication.

I actually went in and had a fantastic conversation with this person, and I could feel myself linking those items, and when I did a feedback email I actually, you know, set it out with, ‘Right, these are the items that need to be provided, this is what we need to be doing’ and then you thought to yourself, “That is all linking back to this Material Citizenship and it’s almost a prescription”. You think about a prescription of medication, don’t you, but actually this is a prescription of things, items within somebody’s life that’s going to make their well-being better, hopefully, and I think that’s just as important as when we’re thinking about medication for an individual. (Interview 17, Manager)

Two interviewees (Sites 2 and 3) gave examples of facilitating the transition to the care home by encouraging residents and their family members to think of functional objects and things to make a room homely. They felt they were able to have a discussion with the residents and their family about why these objects are important.

So, I said, ‘we have to think about creating this room because he’s home and we want him to be comfortable in the home that he lives, to have objects familiar to him to be, yeah, to be comfortable’. (Interview 7, Manager)

Implementation enablers and challenges

While a range of staff types were involved in the training, only a proportion of staff at any site took part. This might explain why the most frequently identified barrier to the implementation of the training (mentioned by staff at sites 1, 3, and 4), was not having all members of the team on board. While some argued for the need to provide training for more staff, others recognised their own role in spreading and embedding the training. There was evidence of both managers and carers challenging practices that did not embrace Material Citizenship™. Some managers described how they were recognising the needs of team members who had not taken part in the training, and two described increased confidence in leading and motivating their team. However, at one site there was anecdotal evidence from the Material Citizenship™ trainers that management were not actively involved in supporting Material Citizenship™ in the home. Managers at two sites considered Material Citizenship™ as a useful toolkit for staff.

It’s helped quite a lot because what I try and do in my role is I try and give the teams the biggest tool bag of stuff that they could possibly draw from, so Material Citizenship™ is another tool to put in that bag. (Interview 16, Manager)

Task orientation and lack of time were also mentioned barriers. One participant noted the additional time needed to provide individual attention to residents. Another noted severe staffing issues at the time of implementation of Material Citizenship™. Three of the managers/care leads recognised how care work was very task-oriented, with one of them recognising the need to give permission to staff to take time to involve residents in tasks.

I think here as a team, they need to almost learn that they can take this time to interact, it hasn’t always got to be task, task, task (Interview 17, Manager)

A small number of staff at three of the homes felt that there was sometimes a lack of resident engagement with activity and use of functional objects, and a lack of understanding among family members.

You get like residents saying, ‘I can’t do that’, ‘Well, let’s just try’, ‘Oh, I can’t do that’, ‘Well, let’s try and then you can say you can’t do that’. (Interview 35, Manager)

The training emphasised the importance of documentation to evidence Material Citizenship™, and some participants recognised the importance of this for communicating information about a resident to other team members. There were reports of changes to documentation practices from people in different roles, including carers, managers, and hospitality staff. Several mentioned a change in awareness of the importance of documentation, and of the need to record the smaller interactions as well as the more significant ones. In addition, participants at three of the sites (2, 3, and 4) mentioned ensuring Material Citizenship™ was included in care plans. However, the documentation process was often seen as problematic to fit into a busy day, and it seemed there was still room for improvement in practice. Several care staff found the training content on documentation more difficult to understand, as they did not have experience of this aspect of care work.

And for the care team, I think it’s exactly the same thing as well, you know, they have that meaningful moment, but then something gets their attention, and then something else gets their attention, and then by the time they remember, it’s like two o’clock in the morning and you can still document it, but kind of the moment’s gone after that. So, I think that’s our biggest hurdle, it’s something that we need to work on. (Interview 38; Manager)

A fundamental part of the training is an exploration of identity and how risk-averse behaviour can reduce or remove a resident’s ability to demonstrate who they are and how they would like to live. The perception of risk was identified as both a barrier and facilitator of Material Citizenship™. Risk aversion was mentioned as a potential barrier by one or two participants at three of the sites, with recognition of the generally risk-averse nature of caring, concern about possible scrutiny of adverse events, and the need to address family concerns about safety. However, following the training, there appeared to be a shift to less risk aversion and more positive risk assessment at three of the sites. Staff at these sites talked about changes in their considerations of risks when residents used functional objects. This is illustrated in the interview below regarding a resident’s use of a razor.

We have a lady here who has the start of dementia and she’s absolutely paranoid about having hair on her face. She will sit on a daily basis with an electric razor and shave her face, which obviously naturally makes her face sore because of doing it repetitively. I saw her the other day and she said, ‘Oh, they’ve taken it off of me’. I said, ‘What’s that?’, and she said, ‘My razor’. I went and spoke to the member of staff, and I said, ‘Where is her razor?’, and she said, ‘We’ve put it in the cupboard because she’s made her face really sore’. I was like, ‘Okay, I appreciate that, but she knows she’s making her face sore, and she still wants to do it. Maybe we should support her to put cream on afterwards, or maybe it’s the habit of doing it, so you can get those facial rollers, can’t you? There’s more we can do than just saying to someone, “No, we’re taking that away from you”, because she maybe doesn’t understand why we are’. Obviously, I might not have thought like that if I hadn’t had that training, because she was doing it to keep her safe, whereas because I’ve had the training, it was a bit like, actually, we can facilitate this, we can do more to support her to do it. (Interview 2, Manager)

Material Citizenship™ also gave staff confidence to defend positive risk taking in their practice more broadly. In the following quote, a carer describes how she consequently felt confident to argue for a care practice which involved a level of risk, but also allowed a resident to have more independence.

I think if I’d had that conversation with [my manager] before [the training], I’d have been like, oh my god, yeah, they’re really going to have us for that, but then I quite confidently was sort of like, we’ve done everything we can to eliminate the risk, there’s nothing else we can do. We’ve tried to have a conversation with her, she still wants to get up and go to the toilet on her own. We’ve put the sensor mat in place so we get there as soon as we can, there’s nothing else that we can do. And I’d quite happily sit there and have a conversation about that with a CQC [Care Quality Commission, UK regulatory body] inspector. Whereas before, I probably would have been a bit like, oh god, we should be doing more. (Interview 5, Carer)

Managers from two of the homes (Sites 3 and 4) spoke about processes to embed the practice of Material Citizenship™ within their teams/care homes. Several talked about leading by example and including Material Citizenship™ in their induction processes. One wanted to create a community of excellence across two care homes before spreading to other homes within their group. One spoke of the value of having a team of people to drive the practice, and the need to embed the practice in the care plan. Another manager valued continual support and mentorship from the Material Citizenship™ team.

For me, it’s just a case of really getting it into the care plan in a structured way that, yeah, that makes sense to people and it’s [a] SMART [goal], like people actually use it, it’s not something just put in there and left alone, it’s something that’s going to be used. (Interview 38, Manager)