Healthcare Support Workers Working With People With Dementia on Mental Health Wards: A Practice Model Informed by Care Aesthetics

Introduction

In the United Kingdom (UK), it is estimated that around 1 million people live with dementia, with that figure set to rise to 1.2 million by the year 2040 (Livingston et al., 2020). As the literature and demographic trends suggest, most people with dementia prefer to remain at home and in a familiar neighborhood network (Alzheimer’s Society, 2014; Keady, 2024). However, as the disease progresses to its more advanced stages, additional care is needed and some people with dementia move into a care home or other assisted living environment (Alzheimer’s Society, 2014). A smaller number of people with dementia are compulsorily admitted into National Health Service (NHS) mental health wards for older people, often under a section of the Mental Health Act (1983), for an assessment of their dementia because of the complexity of its presentation and the potential risk to the person or to others (Edmans et al., 2022; Jones et al., 2023a, 2023b). These specialist wards are usually located in NHS Mental Health Trusts and operate as locked environments of care, with entry and exit to the ward secured and under the control of ward staff. Wards may be structured either as “dementia-only” or “mixed,” with the latter also providing care to those with functional mental health conditions, such as late-life psychosis (Pinner et al., 2011). Admissions to mental wards for older people come from general hospital wards, care homes, and domestic homes (Edmans et al., 2022). Following a period of assessment and intervention, and an associated reduction in risk, patients are discharged to the most appropriate location; this is most often a long-term care setting, but for a smaller proportion of patients, this could be a return to the domestic home (Edmans et al., 2022).

The literature also reveals that such compulsory admissions result in a high level of stress for family members who undergo a transition of role identity from that of primary carer to ward visitor (Partridge et al., 2025; Wolverson et al., 2023). As Partridge et al. (2025) go on to suggest, for family carers of people with dementia, this abrupt change requires additional understanding and support as families are often undergoing traumatic pre- and post-admission experiences and uncertainty over where their relative will be discharged to. Despite the complexity and vulnerability of people with dementia admitted to these wards, and the impact on family carers, these environments of care have largely been overlooked in research practice (Jones et al., 2024; Partridge et al., 2025; Ross & Dexter-Smith, 2017; Wolverson et al., 2022).

Mental health wards for older people are staffed by ward-based staff, such as mental health nurses and healthcare support workers, as well as a broader multidisciplinary team (Edmans et al., 2022). In the UK, the term “healthcare support worker” (hereafter HCSW) is an umbrella term used to represent a range of “unregistered” healthcare support roles, including healthcare assistant, nursing auxiliary, and occupational therapy assistant, who work under the supervision of “registered” staff such as mental health nurses and allied health professionals (Griffin, 2023). HCSWs account for nearly 28% of the NHS workforce and are notable for the high-patient-facing nature of their roles (Griffin et al., 2024). On mental health wards for older people, HCSWs represent the largest staff group, with more HCSWs on a given shift than mental health nurses (Edmans et al., 2022).

In terms of training in the United Kingdom, while “registered” staff are taught on university courses adhering to national regulator guidance (e.g., Nursing & Midwifery Council, 2023), HCSWs as “unregistered” staff have no mandatory and standardized training, with most learning on-the-job from working alongside role models, by attending in house training, and through supervision from registered staff (Griffin, 2023). Several influential reports have highlighted that regulation, training, and development of HCSWs needs to be improved (Cavendish, 2013; Francis, 2013) but also that this staff group has significant untapped potential (Palmer et al., 2021). The Care Certificate was launched in 2015 to provide minimum standards for training, supervision, and assessment for staff new to health and social care (Skills for Care, 2025), and this includes standards relevant to mental health and dementia (Peate, 2016). While many NHS Mental Health Trusts have adopted the Care Certificate, this remains voluntary and inconsistencies in support and training remain for HCSWs (Palmer et al., 2021).

Given their high rate of patient-facing duties and the associated impact on the patient experience, there is a surprising lack of research exploring the training, skills, and roles of HCSWs in mental health wards for older people. For example, a recent qualitative systematic review of the literature on HCSW practice with patients with dementia on NHS acute and mental health wards for older people (Kindell et al., 2025) found only 19 published articles, with many studies stemming from the same data set(s). The review highlighted the crucial role that HCSWs have with personal care, such as washing, dressing, and feeding people with dementia. While there were similarities in HCSW everyday caring practices between the acute and mental health wards for older people, Kindell et al. (2025) drew the conclusion that, owing to the level of risk and behaviors that challenge experienced by people with dementia on the mental health wards, HCSWs required:

A high degree of skill in communication, including verbal skills as well as embodied interactional skills such as facial expression, movement, touch etc., to maintain a person with dementia’s dignity and cleanliness and to provide for their physiological and safety needs. (p. 11)

Although the Care Certificate identifies standards for communication, we would suggest, this lacks a focus on the higher levels of interactional expertise needed for frontline practice with people with dementia admitted to mental health wards for older people.

Focusing on the sensory, embodied, and relational practices required within personal care and other health-related tasks aligns closely to the field of care aesthetics (Thompson, 2022), which draws on feminist care ethics to shine the brightest of spotlights on the importance of the micro-practices of care, such as touch, tone of voice, and bodywork. Here, “aesthetics” is used to refer to the experience of all the senses within the care relationship, not a narrow idea of how something looks (for an exploratory application of care aesthetics to dementia care practice, see Campbell et al. (2024) and Jones et al. (2024)). Care aesthetics, therefore, builds on the care ethics literature exploring the broader field of care (e.g., Mol et al., 2010) and the sociology literature that addresses the place of bodywork in health and social care (e.g., Twigg et al., 2011), with an aim to draw out and study in detail the sensory, embodied, and relational aspects described within these fields. In terms of HCSWs, this allows for exploration of skills that have been learnt and crafted over time through on-the-job experience in direct patient contact, a lens that is outside of the traditional NHS hierarchy in terms of qualifications and pay grades.

At present, there is no model of care that captures HCSW practice for people with dementia on the mental health wards for older people or positions their work within a theoretical and/or relational framework. This study therefore aims to provide a first step in this direction by (i) making visible the invisible aspects of HCSW care practice through the detailed lens of care aesthetics and (ii) inductively generating a practice development model that focuses on everyday HCSW care practices in this specific ward setting.

Methods

Data Collection

We adopted a case study design (Yin, 2009) to refine and clarify our understanding of care aesthetics in this practice setting using two complimentary qualitative approaches: (i) ethnographic observations on the ward and (ii) CLGs using an exploratory, participatory action research (PAR) methodology (Fogg et al., 2022). Table 1 outlines a summary of the methods of data collection used in the study.

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Table 1.

Summary of Methods of Data Collection

Case study methodology: mixed qualitative methods (over 20 weeks)

Data collection carried out in parallel:

(1) Ethnographic observations (3 wards across 2 sites)

○ Nonparticipant observation (2 researchers)

○ Snapshot interviews to clarify observations

○ 28 hours at each site (56 hours total)

○ Data—detailed field notes

(2) Collaborative learning groups (2 sites)

○ Participatory action research methodology

○ 2 researchers at each group

○ 6 collaborative learning groups at site 1 (5 HCSW participants)

○ 6 collaborative learning groups at site 2 (4 HCSW participants)

○ Data—reflective notes written during and after groups by researchers, drawings and writing produced by participants, and photographs of objects and body positions (60 photographs).

In total, and outside of the CLG activities, the researchers conducted 28 hours of HCSW observation at site 1 and 28 hours at site 2. The ethnographic observations were further enhanced in the form of snapshot interviews conducted by the researchers during real-time situations on the ward to clarify and better understand what was being seen at the time (should the conditions and patient care priorities allow). Observation notes were used as the basis of activities for the planned CLG sessions.

To co-develop the practice development model, a series of six CLGs in the two sites were conducted by the researchers with participating HCSWs. All CLGs took place on NHS premises and in rooms adjacent to the participating wards set aside for staff learning/multi-disciplinary team meetings. The six sessions, all one-hour long (apart from one 45-minute session), were structured as follows: (1) and (2) “Getting to know” one another and sharing experience of care; (3) How do we care? (4) How do we notice care? (5) How do we value care? and (6) Explore study findings to date. These sessions were delivered by both researchers one day apart between the two sites to enable cross and simultaneous learning and reflection to take place, and in line with a PAR approach. Photographs of HCSW caring practices and materials/objects that they believed were important to their everyday work and role identity were also taken during the CLGs, with 32 photographs taken in site 1 and 28 in site 2. Table 2 outlines the structure and activities conducted at the CLGs.

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Table 2.

HCSW Collaborative Learning Groups: Structure and Activities

	Topic discussed	Site 1	Site 2
		N° staff	N° staff
		Ratio M:F	Ratio M:F
Group 1	Introduction to the project	2:1	3:1
	Getting to know one another
	What is your experience of care?
	Sharing stories of care
Group 2	Repeat of previous session	0:4	0:1
Group 3	How do we care?	1:2	3:0
	Breaking down care tasks, listing the steps and skills used in:
	• Shaving
	• Waking someone up
	• Putting someone to bed
	• Getting someone out of a chair
Group 4	How do we notice care?	2:0	2:0
	What elements do HCSWs pay attention to when performing a care task?
	Embodied demonstrations of care and photographs
	Collectively deciding on skills
Group 5	How do we value care?	0:2	3:0
	Thinking about a scale of care, e.g., “bad/standard/extraordinary” care with examples
	What does this scale tell us about care?
	Collectively agreeing values important for care
Group 6	Explore study findings to date	2:3	3:1
	Sharing sensory and embodied skills described across the study
	What is the journey of these skills—how do we get to know what helps an individual patient?
	What happens to this knowledge on discharge?

Both researchers kept reflective notes during and following each CLG, and these notes were used as data. All CLG outputs produced by the HCSWs and the researchers were collected at the end of each session and transcribed. Summaries of these transcriptions were used at the start of the next CLG session as a reminder of previously undertaken work and as part of the data set for constant comparative analysis (Glaser, 1978; Glaser & Strauss, 1967).

The two researchers engaged in reflective sessions after each ward visit, to sense check the data and gather any additional insights. Members of the research team met weekly across the 20-week study to discuss any issues arising from the research work, including the experiences of the two researchers on the mental health wards for older people, and conduct emergent data analysis.

Findings

Figure 2 shares the HCSW practice development model that emerged to define everyday practices with people with dementia admitted to NHS mental health wards for older people. Each of these separate but interconnected stages will be defined and explored in turn, starting on the left of Figure 2 with “sensory, embodied, and relational practices” and then moving across the figure to “being co-present.” In our model, and with all the stages in the model working in harmony, “being co-present” is the descriptive meaning and practice outcome that HCSWs strive to achieve in their everyday work with people with dementia admitted to NHS mental health wards for older people.

In the supporting writing in the Findings section, a key relating to the data strands is provided along with the date this was collected; for reference, this is: S1 (site 1), S2 (site 2), Ob (observation data), CLG (data from CLG), and Rf (reflection sessions). Both main researchers will be referred to by their initials, and, at times, we refer to the CLG number (1–6) where the data strand was located. We will also use the terminology “person with dementia,” “people with dementia,” and “patient with dementia” depending on the situational context and shorten the location of the site of the research to the “ward.”

Discussion

This article has drawn on mixed qualitative methods to deliver an in-depth understanding of the everyday care practices carried out by HCSWs working with people with dementia admitted to NHS mental health wards for older people. Despite the important patient-facing nature of their role, to date there is a paucity of studies exploring the practice of this group. Analysis has provided an explanatory and dynamic model of HCSW practice grounded in the direct experiences of this staff group and underpinned with the language and relational concepts of care aesthetics (Thompson, 2022). A previous review has described the presence of HCSWs on hospital wards with a key theme of “always being front and center” (Kindell et al., 2025), which details the continual physical presence of HCSWs out on the ward floor and their crucial role in meeting personal and healthcare needs. The analysis here takes this a step further in terms of considering “being co-present” as a theoretical abstraction and linking scheme that describes the meaning and outcome of HCSW practice with people with dementia on NHS mental health wards for older people. As we define it, “being co-present” is both a spatial and temporal idea that suggests that attending to the “here and now” is a vital aspect of quality, person-centered dementia care orientated to the “in-the-moment” well-being of the person with dementia.

This alignment is pertinent for the physical location of the study as patients with dementia on the NHS mental health wards for older people had significant difficulties with communication and were reliant upon additional non-verbal support for interaction, including the use of touch, facial expression, and body movements. Additionally, patients with dementia were admitted to the ward because of their considerable challenges with behavior and/or pronounced levels of risk, and this meant that mood, interaction, and/or the ward atmosphere could change rapidly, requiring appropriate supportive action from the ward team, including HCSWs. Moreover, as a locked environment of care, HCSWs needed to support all of those within the ward space (i.e., patients, colleagues, and visitors) and to quickly “tune in” to any shifts in the ward atmosphere, such as a sudden increase in noise and movement, to engage with people with dementia who may be unable to feel, or relay, this experience themselves (see also: Richardson & Campbell, 2024; Sumartojo et al., 2020). It was this rapid ability to “tune in” and attend to the sensory attributes of the ward that operationalized and applied the values and principles of care aesthetics and helped to articulate the skilled care practices of HCSWs.

As seen throughout the study findings, and in Figure 2 especially, care aesthetics also provides a framework to analyze the micro-practices of care, including the expertise required to deliver person-centered care (Kitwood, 1997), and respond to the values of “positive person work” which includes recognition, negotiation, collaboration, and facilitation. Two areas within Kitwood’s (1997) original formulation of “positive person work” are a focus on “play” and “timalation,” both of which, we would suggest, have received limited attention in the literature or practice context since the publication of Kitwood’s seminal text. However, “play” is described by Kitwood (1997) as an exercise in spontaneity and self-expression and an experience that has value in, and of, itself. In our data, this can be seen within the formalized activity sessions conducted by HCSWs on the ward, but also, crucially, in spontaneous interactions that are a part of everyday care practices, such as using banter, dancing, and singing with patients with dementia on the ward. Furthermore, “timalation” refers to forms of interaction which target the senses and provides contact, reassurance, and pleasure (Kitwood, 1997). During observations, HCSWs were regularly seen to rub shoulders, stroke and hold hands, or sit closely alongside the person with dementia to provide reassurance. Attention to the sensory experiences was not just to complete care tasks; these acts of “timalation” often occurred outside of such a setting and provided important embodied and relational experiences in themselves. Person-centered care also extended to “tuning in” to the needs of family members on the ward, as evidenced by the support provided around visiting in the example above. Given the significant emotional challenges for carers in this setting (Partridge et al., 2025; Wolverson et al., 2023), this would appear to be a vital aspect of the HCSW role.

The model in Figure 2 also highlights how the senses and the body are used within a care relationship and explores how both participants, that is, in this context the HCSW delivering the care and the person with dementia receiving it, are experiencing the encounter on a sensory level. There were numerous examples in the data where care was not just delivered; it was embellished using thought and foresight and to consider the person with dementia’s experience “in the moment” (Keady et al., 2022). For example, as theatre scholars, the researchers on this study (KM-R; RP; and JT) were continually struck by the performative nature of the care work that was on show on the ward and the ability of HCSWs to spontaneously, and creatively, improvise in the moment. As an illustration, and as shared in the article under the “Tuning in … to the person with dementia” category heading, when a person with dementia was embodying the actions of “fishing” on the ward, the person then handed an imaginary [to us] “fish” to the HCSW who then chose to carefully take the “fish” and enter the person’s world. What followed was a sustained interactive performance by the HCSW that upheld the self-esteem and embodied actions of the person with dementia on the ward who was, indeed, “fishing.” Interestingly, this decision by the HCSW to accept and go along with a situation of altered reality (rather than challenge it with the “truth”) is currently conceptualized in the dementia studies literature as entering a state of “therapeutic lying,” an area that presents as potentially contentious in healthcare (see Elvish et al., 2010; Murray et al., 2025), as well as difficult to define, due to the nuances of non-truth telling in daily life (see Williamson & Kirtley, 2016). The interactive choices inherent in such encounters have most often been explored with respect to managing a person with dementia’s distress and what to say in response to repetitive questions (see Pilnick et al., 2025). However, if we stand back and view the interaction with the “invisible” fish through the lens of theatre performance, this could be framed as a linked association between “play” and “improvisation” (Dowler, 2013), both of which have a long history in theatre studies (Spolin, 1963). The actions used by the HCSW represent not just verbal responses but, arguably, also responsive embodied acts which layer the interaction with creative improvisation. Such a performative and descriptive lens engenders a more sensitive and relational way of describing these everyday supportive acts and caring moments.

A lens of improvisation can help important questions to be surfaced to underpin reflective practice, such as “if you do step into someone else’s reality, what part will you choose to play?” So, for example, in terms of supporting the person with dementia who, in our study, was in “work mode” as a cleaner, an HCSW could choose to become a co-worker and enhance camaraderie or instead become a supervisor and ask the person with dementia to make sure they have not “missed a spot there”—as played out in Claudia’s example, with potential for either stance. Further research is required to explore this area, but performance practice could provide an opportunity to reposition these interactions as creative holistic encounters where the skills are in “tuning in” to the person with dementia and their experience of lived time.

The contextualized nature of care experiences also demonstrates the numerous choices and decisions that HCSWs are required to make throughout their day, such as how best to attain cooperation when communication and consent is significantly compromised, and manage refusals to engage and other challenges with behavior. HCSWs spoke about prioritizing the patient’s well-being within their decision-making rather than focusing on completing the task by, for example, leaving a person who might be refusing to get dressed and returning a little later to try again when the person with dementia may be in a different frame of mind. However, HCSWs are faced with considerable ethical complexity within their work, including the issues discussed above in terms of altered reality and practical challenges, such as how often or how long to postpone a personal care task during instances of refusal and the consequences of this in terms of dignity and needs, and how this might then impact personal well-being. The high frequency of these ethical issues in the everyday care of people with dementia and the associated training needs has been recognized in other work (Kindell et al., 2025; Nuffield Council on Bioethics, 2009). In this sense, while the overall frame of HCSW work was delegated by the registered staff on the ward, within their everyday care practice, HCSWs were required to make numerous “in-the-moment” decisions on how best to deliver care which, we would suggest, are aligned to their intuitive and skilled ability at “tuning in” to a situation.

Finally, care aesthetics offers a language that might contest the well-established hierarchy of NHS staffing, with HCSWs currently at the bottom of that ladder because of their lack of recognized professional qualifications. Care aesthetics draws attention to the “craft of care,” and this means that staff with few formal qualifications can be actively celebrated as highly skilled experts in their craft, contributing to high-quality care and, potentially, to the development of other workers. There is debate on how these skills are acquired, for example, whether the skills represent an innate part of the worker (Smythe et al., 2015) or if they are acquired via informal ways of learning (see chapter 3 in Surr et al. (2023) for further discussion of this area). While care aesthetic theory would argue skills are honed over many years of personal and vocational experience (Harman, 2021; Thompson, 2022), further research is needed to explore how HCSWs can be supported to more effectively “tune in” to themselves, their values, and their craft. This has significant implications for staff training, well-being, and retention, areas all recognized as requiring further and urgent attention in the NHS (Griffin et al., 2024; Hall et al., 2024).