A Qualitative Evaluation of The Little Things Training for Diverse Background PCAs in Aged Care

Abstract

Most direct residential aged care is provided by personal care assistants (PCAs), with western societies increasingly relying on culturally diverse aged care workers. In Australia and internationally, studies have reported that the level of training in both instrumental and relational care for PCAs is insufficient and inconsistent. This study evaluated the impact of The Little Things training program, designed for culturally diverse PCAs and students training to become PCAs. A modified Most Significant Change process, comprising a group-based qualitative analysis of narratives, was used to gain a rich understanding of the impacts and outcomes of the training. Narratives supplied by 29 PCAs and students were reviewed with aged care and training organization managers, who identified six themes: Increased confidence; Taking time; Building rapport and collaboration; Awareness of new skills; Seeing the whole person; and Positive impact on the resident. These themes reflected two key aims of The Little Things training: improving PCAs’ communication with residents and increasing PCAs’ confidence in communicating with residents. The study findings showed that The Little Things training program can improve the confidence of PCAs to communicate with aged care residents and may improve their capacity to form relationships.

Background

Within the context of an aging population, Australia—which is representative of many other OECD countries in this respect (OECD, 2024)—currently has two related challenges within aged care; namely the quality of care provided and adequate staffing. Most aged care in OECD countries is provided by nursing assistants, many of whom are from migrant or culturally diverse backgrounds (Australian Government Department of Health, 2020; OECD, 2020). Educational standards for this workforce are particularly low (OECD, 2020). In Australia, in addition, the vocational training of Personal Care Assistants (PCAs) has often been reported as insufficient, inconsistent, and of poor quality (Commonwealth of Australia, 2021b; Martyn et al., 2022; Meagher et al., 2019).

While the importance of relational care has long been recognized, an explicit training focus on the micro-skills—the little things— that contribute to relational communication in the personal care context has been missing (Mackey, 2018). This is particularly a problem among migrant personal carers who may lack confidence in communicating in the dominant language. The need for training in relational care is underscored by the widespread adoption within the aged care sector of “person-centered care” (Aged Care Workforce Strategy Taskforce, 2018). The current study evaluated an Australian training program, The Little Things, designed for PCAs from culturally diverse backgrounds, that addresses the relational-care gap in the training currently provided.

Person-centered care encompasses the provision of not only physical well-being, but also mental and social-emotional well-being (World Health Organisation, 2015). A classic principle of person-centered care is that the person receiving the care has “a standing or status that is bestowed upon [them] . . . by others, in the context of relationship and social being [which] . . . implies recognition, respect and trust” (Kitwood, 1997, p. 8). The signs of recognition, respect, and trust are patterns of behavior that are built-up over time by social interactions that go beyond practical, routine care. Relational care is therefore an essential characteristic of person-centered care (McCormack et al., 2017).

Attuned relational care can be seen through the theoretical lens of politeness theory, which posits that in all cultures the use of language in social interactions makes assumptions about “face”: that is, the social conditions for maintaining self-esteem (Brown & Levinson, 1978, p. 59ff). Brown and Levinson (1978) argued all persons are motivated to maintain “negative face” (i.e., freedom from interference and impositions within their personal space) and “positive face” (i.e., affirmation of their public self-image or self-concept). This maintenance of face is essentially what constitutes politeness; however, while universal at a formal level, there is cultural variability about what constitutes face-threatening acts based on shared understandings and expectations (i.e., what the content of maintaining face consists of in specific contexts). For example, aged care residents’ reactions to staff use of informal speech, humor, and praise while carrying out personal routine tasks varies by culture (Backhaus, 2009). The kind of intimate, personal tasks (e.g., assistance with toileting) that PCAs routinely assist with makes “everyday life at a nursing home . . . fraught with face-threatening acts of an exceptionally severe nature” (Backhaus, 2009, p. 58). Adequate relational care training may ameliorate these perceived threats to face by making cultural assumptions explicit (e.g., about the appropriate use of language in different contexts within the local aged care setting).

Given the clear importance of relational care, which is highly context dependent, there is a need for consistent training to help culturally diverse PCAs to develop their awareness of the pragmatics of language (Barón et al., 2024; Small et al., 2015). This need is underscored by findings that both aged care residents and PCAs report seeing the care relationship as primary in the delivery of care (Martyn et al., 2022; Walsh & Shutes, 2013). Relational care includes sensitivity to how the “little things” matter in forming and maintaining relationships between staff and residents. These “little things,” such as softening commands (by couching them as suggestions or questions about what the resident might “like” to do now), can be easily missed in a busy schedule. Such indirect strategies indicate “interest in the resident beyond purely task-oriented topics” (Marsden & Holmes, 2014, p. 25). Learning about and understanding the influence of these subtle interactions on an aged care resident’s sense of self can help build culturally diverse PCAs’ confidence in providing relational care (Mackey et al., 2022).

The Little Things Training Program

The Little Things training program was based on prior research conducted by PJM and IH, who designed the training program, which was implemented in 2019 and early 2020. The training was designed for people who were training to be PCAs or who were already in employment in this capacity. In both cases, a minimum level of English language skills is required as a prerequisite.

The training involved a 3-hr, manualized, face-to-face program designed to be fun and engaging. The training resources were produced with input from carers, older people, and industry experts. Training materials included: six training films depicting effective use of communication skills in aged care, based on authentic interactions between residents and PCAs from culturally diverse backgrounds; and communication activities (games and role plays) to facilitate exploration of The Little Things concepts in the context of participants’ own experience. The training package was designed for flexible delivery and allowed for short, informal training sessions in addition to longer, more structured formats.

The Little Things training was targeted at PCAs from diverse cultural backgrounds, who currently comprise about 30% of the aged care workforce in Australia (Morrison-Dayan, 2019). While aged care residents have reported culturally diverse PCAs as being as helpful as Anglo-Australian PCAs, and in some cases more helpful in terms of relational care (Shrestha et al., 2023), other studies have reported important communication deficits in the former (e.g., Ngocha-Chaderopa & Boon, 2016). Thus, the stated aims of The Little Things training were: to improve communication between PCAs and the older people they care for; to improve the confidence of PCAs from culturally diverse backgrounds in communicating with aged care residents; to reduce complaints about PCAs’ communication skills; and to improve the employment prospects of participating PCAs and Registered Training Organization (RTO) students. These goals are particularly salient given the recent Australian Aged Care Royal Commission’s report, which reported that an accumulation of “small oversights . . . can amount to neglect” (Commonwealth of Australia, 2021a, p. 71).

Evaluation of The Little Things training comprised qualitative and quantitative components and was led by YW, who had not been involved in the original research, program design, or implementation phases of the project. The previous report of the quantitative evaluation results by Mackey et al. (2022) showed that after participating in The Little Things program PCAs and PCAs-in-training reported more confidence, better communication skills, and a shift in priorities to more relational communications when interacting with residents, relative to controls. However, this component of the evaluation did not capture the nuance of the trainees’ experience of the program, which is explored in the present study.

The Study

The aim of the current study was to evaluate the impact of participating in The Little Things training program for PCAs, particularly those from culturally diverse backgrounds, using a narrative approach. To this end, the current study adopted a qualitative analysis of impacts of the program and how learnings from the program were received by RTO students and applied in the field by practicing PCAs, and to what extent these addressed the key aims of The Little Things training. A modified Most Significant Change method was used to complete this evaluation.

Methods

Design

The qualitative technique used in the current study was a modified form of the Most Significant Change (MSC), which may be used for assessing whether a program has achieved its stated aim(s) (Dart & Davies, 2003; Regan & Wells, 2017). The MSC explores and identifies perceived significant impacts of a target program through dialogue between key stakeholders, reflecting on real, concrete examples of how the program has been implemented and its outcomes. It is an inductive, flexible, and iterative approach, eschewing fixed performance indicators and deductive inferences (Dart & Davies, 2003). The MSC is particularly valuable for monitoring and assessing new programs where not all outcomes can be confidently described in advance. The MSC has been modified for diverse evaluation purposes (Serrat, 2017), including: creating learning opportunities in family planning programs in developing countries in Asia and Africa (Saori et al., 2022); and rapid assessment of food systems (Fink Shapiro et al., 2021).

The present study used a modified MSC method to assess whether the stated aim of improving diverse background PCAs’ confidence in relational interactions was realized after participating in The Little Things training program. Modifications to the MSC process included fewer stages (given the relatively small size of the program) and adjustments to comply with COVID restrictions, including the use of online communication. Consistent with the MSC methodology, no a priori assumptions or hypotheses were made on the likely themes that would be used to group the stories.

Participants

Participating organizations included four providers of residential aged care and three Registered Training Organizations (RTOs) that provided basic training (Certificate III in Individual Support (Ageing and Disability)) for PCAs. Eleven PCAs and 17 registered training organization (RTO) students, who attended the training and volunteered to be interviewed about their experience, provided stories for the MSC method. Twenty-three of the interviewees were from culturally diverse backgrounds; five were Anglo-Australian. Participants in the MSC workshop included six managers from four aged care providers and four managers from RTOs, as well as YW and KS from the research team; PJM and IH; and administrative support from SH.

Ethical Considerations

This study received ethics approval from St Vincent’s Hospital and La Trobe University (HREC 231/18) on 7th December, 2018. All interview participants had sufficient English language skills to provide informed consent.

Procedure

The facilitator of the training (PJM) asked participants of The Little Things training trial if they would like to volunteer to be interviewed two-to-three weeks after completing the training. For those who agreed, interviews were conducted between 3 March and 6 April 2020. The interviewer (YW) asked participants: “When you think about The Little Things training, what do you think was the most significant change?” and “Why is this change the most significant one? Most interviews took place face-to-face at participants” workplaces or training locations, but five were conducted online because of COVID-19 restrictions. All participants interviewed for MSC stories were given a $30 AUD voucher after the interview.

Author YW conducted and recorded 28 interviews, ranging in duration from 3 to 34 min with an average of 11 min. Interview duration was much longer for the interviewees from RAC homes (average 16 min) than the RTOs (average 8 min). Some interviews were very short because of participants’ limited capacity to use spoken English. Eight interviews resulted in stories that were judged by authors YW and PJM as not detailed, coherent, or well-expressed enough to be included in the MSC workshop; four of these were provided by native English speakers.

After being transcribed and de-identified, 20 stories were developed by one of the research team (YW). Developing stories involved formatting the material as narratives (e.g., by adding or amending wording so that the participant’s intent was clear) and removing clearly extraneous material. Stores were presented in a workbook that included the aims of the program. All stories were headed with a one-row table with columns for “In scope (Yes/No),” “MSC,” “Reason,” and “Theme.” Four of the remaining 20 stories were pre-processed as examples in advance of the workshop and text was inserted into the short tables heading these stories. The workshop was hosted online due to COVID-19 restrictions and was chaired by YW. The workbook was emailed three days in advance to workshop participants so that they could prepare by reading the stories and thinking about the most significant changes described. These stories were then analyzed in an online meeting in May, 2020 (scheduled to last 4 hr, including breaks, and recorded to enable details to be checked), using the following stages:

• Stage 1: Processing the stories and recording the discussion. A few minutes were allowed for workshop participants to read each story before it was processed. Processing each story included deciding on whether the story was in scope (i.e., whether it was about a change and sufficiently detailed to identify this change), choosing a short label, and identifying the most significant change(s) and reasons why this was/these were the most significant. Some reasons why these changes were most significant were identified by interview participants with sufficient English language capacity, but others were identified by workshop participants in discussion. The workshop chair shared her screen and used the tables heading each story to record key details as participants suggested them. After processing each in-scope story, these one-row tables were combined into a master table and emailed to participants during a scheduled break in the workshop. Participants could choose to print out these master tables for reference in following stages.

• Stage 2a: Grouping stories and deciding on themes. An online whiteboard function within the Zoom online platform was used to record discussion about the stories. The facilitator asked participants to nominate possible themes, which were typed onto the whiteboard. As each theme was suggested, stories were allocated, using story numbers and descriptions. Stories could be nominated as exemplars of more than one theme. Discussion continued until all stories were allocated to at least one theme.

• Stage 2b: Choosing the best exemplar for each theme and the best story overall. The facilitator asked participants to vote on the best story in each theme. Each participant could vote up to twice in each theme. Votes were recorded on the virtual whiteboard using symbols.

• Stage 3: Comparing themes with the stated aims of the project. The stated aims of the project were read out and the group decided which aims were supported by evidence from the stories, whether any aims were not supported, and whether the evidence indicated unanticipated outcomes (Davies & Dart, 2005).

Results

Six themes were constructed during the MSC workshop: Increased confidence; Taking time; Building rapport and collaboration; Awareness of new skills; Seeing the whole person; and Positive impact on the resident. The following sections provide excerpts from exemplars of MSC themes, and the reasons identified for the exemplars, grouped by the six themes. In some cases, the reasons have been paraphrased to make them more concise.

Theme 1: Increased Confidence

Six stories were grouped under the theme of increased confidence. This theme applied especially to the students training for their Certificate III in Individual Support (Ageing and Disability), only a few of whom had any experience in aged care. The selected exemplar of the theme was a story entitled “Grumpy.” The student learnt that he needed better communication skills than he had previously thought, and this helped him understand how he might deal with residents who were resistive to care or feeling grumpy.

Definitely, learning from that training made me feel a little bit confident speaking, talking, communicating with them. Confident because I never knew that there are lots of ways of communicating. I thought what I know is enough. I learned that there are other words, to tell them in a nice way and not in a way that might be uncomfortable for them or may disappoint them. I learned that communicating with those type of people is a little bit different. That’s why I really appreciate that training. (RTO student)

The MSC was recognition that it was important to develop relational-care skills and techniques. The reason that this was important was increased confidence to communicate with “grumpy” clients, along with the recognition that communication is broader than first thought, and that choices can be made in communicating.

Theme 2: Taking Time

Three stories were grouped with the theme of “Taking time.” In the exemplar (story entitled “Juice”) the MSCs were identified as using simple words and giving the resident time to make a choice.

I took her [the] drink and . . . I talked to her very politely. “It is for you, it is for your health. [The] doctor has recommended [it] for you. If you don’t want [it] now, you can take it later, [I] will keep it for you.” After some time, she tried [a] little bit, not [a lot] but she tried. (RAC staff)

The primary reason identified was improving the relationship by shifting the power balance toward the older person and telling them that their preferences mattered.

Theme 3: Building Rapport and Collaboration

Seven stories were grouped with the theme of “Building rapport and collaboration,” with two exemplars selected, entitled “Photo” and “Boxer.” The Photo story was so labeled because of a strategy used by the staff member (“I noticed an old photo on the wall and so I was able to build a conversation based on the photo”), while the Boxer referred to an identity of the resident. It was decided to retain both “best” stories in reporting on these themes.

The MSC for “Photo” was a shift in the staff member’s attitude toward seeing someone as a whole person.

[He was] quite resistive in a certain way to our care . . . I noticed an old photo on the wall and so I was able to build a conversation based on the photo. I drew attention to the photo, and I asked him a question. Then the client was able to go back and tell me all about this photo and when it happened, and it just shifted their whole attitude. (RAC staff).

The reasons identified in the workshop were associated with using a more person-centered approach by taking a genuine interest in the whole person.

The MSCs for “Boxer” related to showing empathy and developing collaboration.

He was a boxer in his early days and even now he is so strong that, even if you try to push him, like putting the clothes on, if he’s not ready he won’t let you. So, last Friday, I made him understand. I showed him—sometimes he forgets, and he forgets to communicate—I showed him, “Look, your pants are dirty.” I showed him the dirty pants, like by touching it and showing [it] in front of his eyes. After that he forgot that he was struggling with me, [he said], “Ah, they are dirty they need to be changed.” I got them out and I put the clean ones on. These things, they do matter, a lot. (RAC staff)

Hence, the reasons that showing empathy was a significant change were pragmatic, including being flexible and getting a positive response from the resident.

Theme 4: Awareness of New Skills

Five stories were grouped into the theme of Awareness of new skills. Most stories in this theme were from students, though two were from experienced staff. The two exemplars chosen by the workshop were: “Scared,” provided by a student who was “scared” because she did not previously know how to communicate with older people, and “Shy girl,” provided by a student about how she felt too shy to talk to people until she had the training. It was decided to retain both “best” stories in reporting on these themes. The MSCs were: Learning how to communicate (“Scared”); How to start a conversation (“Scared”); Confidence to talk in front of people (“Shy girl”); and A new understanding of the caregiver role (“Shy girl”). The reasons given were Building a relationship with the client (“Scared”); and The caregiver could see having a future in the industry (“Shy girl”).

I learn[ed] so many things. And also, it teaches me to take care of older people, so I didn’t know that, but now, I learn a lot about how to communicate with [older people] and how to deal with their situation, whether [they have] dementia or [they’re] normal. (RTO student)

When I went for that training, I didn’t know how to communicate with the clients sometimes. I didn’t know where to begin. And after I went there, I learned more about how to communicate with [clients], how to keep your voice down, what simple way[s] you can use, [and to] go step by step. Because I found out that when you talk with the client, if you want the client to go for job [complete a task], you go, “Okay, can I give you a shower?” You take it step by step, and the client will [cooperate with] you. The important [thing] is the relationship with the client. (RTO student)

Here the RTO student showed insight into the little things they might use to build rapport with residents, such as a friendly tone of voice and asking permission to commence on a routine task that the resident may or may not be ready to do.

Theme 5: Seeing the Whole Person

Four stories were grouped into the theme of Seeing the whole person; the exemplar was “Magnificent advantage.” The MSC was: Seeing the resident as a person (using the person’s name); and the reasons given were: Respect was communicated; Building the relationship; and Increased cooperation.

The Little Things, as the name indicates, looks little but has a magnificent advantage for our job. Which means, it looks little, it looks minor, but its impact is major. One little thing, for example, is calling the name of the residents, rather than calling [them] Papa, Mama, when you call them. It motivates them to participate in your activity. I believe that calling [them by] their name has a positive psychological impact on them. (RAC staff)

Here the RAC staff member had insight into the “little thing” (which could make a big difference) of using preferred names when interacting with residents. It might also be noted that this understanding also shows some acculturation to Australian norms, as in some culturally diverse communities calling an older adult by a familiar title, such as uncle or aunty, can be a sign of respect.

Theme 6: Positive Impact on the Resident

Positive impact on the resident was discussed at length, since stories in this theme illustrated changes in the residents’ feelings and behaviors (e.g., happiness, agitation, and cooperation) that were directly related to changes in how they were approached by staff. However, ultimately the group decided that the label for this theme should focus on observable changes in the residents rather than try to cover the relationship between staff and residents as well. (Relationship building was reflected in other themes, especially Building rapport and collaboration.)

Nine stories were grouped into the theme of Positive impact on the resident; the exemplar was “Emotional bank,” provided by a staff member who had heard about the emotional bank in terms of accumulating good feelings in relationships as a resource that could then be drawn upon when needed. The MSCs included: empathy, a non-judgmental attitude, and the confidence to communicate. The reasons given were: The person felt affirmed that communication is not a waste of time; and Residents become less refractory:

Some residents are quite demanding and now I try to understand them and not judge them using more words, like, “It’s okay, don’t worry, I will be here for you, and anytime you need me I will be here.” Something like that. I think they understand that, then the emotions become calm, and [they are] not that resistive, so I think it’s not very much change, but I feel it’s helpful to me. (RAC staff)

It can be noticed here that using the “little things” approach also had a benefit for the RAC staff in terms of satisfaction in fulfilling their role.

How Well do Themes Match With the Stated Aims of the Training?

The Little Things’ aims and objectives are outlined above (see the Introduction). It was agreed that the themes illustrated by the stories supported the first two aims of the training (See Table 1).

Table 1.

Match Between Themes From Reported Training Outcomes and The Little Things’ Aims.

Theme	Match with aims
Increased confidence	(1): High
Building rapport and collaboration	(1); (2): High
Awareness of new skills	(1): High
Seeing the whole person	(1): High
Positive impact on resident	(1); (2): High

Note. Aims: (1) Communication between personal care assistants and the older people they care for is improved; (2) Culturally and linguistically diverse personal care assistants’ confidence in communication is improved; (3) There is a reduction in complaints about communication skills of personal care assistants; (4) The Little Things training will result in improved employment prospects for participating personal care assistants or Certificate III Individual Support trainees.

Stated aims 3 and 4 (to reduce complaints about the communication skills of personal care assistants; and to improve the employment prospects of Certificate III trainees) could not be addressed at this stage of the evaluation. However, workshop participants agreed that improved communication skills had the potential to improve trainees’ employment prospects.

Discussion

The present study was part of a broader evaluation of The Little Things training program and aimed to assess how well the program fulfilled its aims, particularly for PCAs from diverse cultural backgrounds, in terms of improving their confidence in communicating and the quality of their communication. The MSC methodology was used to this end. The findings provide a detailed, complementary picture to those of the quantitative evaluation of The Little Things training (Mackey et al., 2022). The themes that were constructed during the MSC workshop provided evidence that two key aims of the training program—improved communication and confidence in communication for PCAs from diverse cultural backgrounds—were successfully addressed. The other aims—a reduction in complaints about communication and improved employment prospects—could not be directly assessed so soon after the program. A future evaluation of The Little Things training program could target these aims.

The implications of the present study’s findings are important in the context of an increasingly multicultural society and aged care workforce; and in terms of the potential to provide more holistic care by incorporating relatively subtle changes in communication patterns in routine PCA task practices. This study demonstrated that culturally diverse PCAs can learn subtle communication skills to both enhance their professional practice and improve both their, and residents’, experiences in routine aged care activities. It showed that short training on relational care can have a big impact on staff capacity to provide holistic care.

Not many previous studies have focused on improving the care behaviors of PCAs. One that reoriented professionals and non-professional staff to relational aspects of care showed that this approach was superior to a focus on routine practical training only (Karimi et al., 2020). The theme “Seeing the whole person” speaks to not assuming that person-centered care is routine in aged care and does not require any specific training (cf Pakkonen et al., 2023; Sloane et al., 2004). Arguably, those who took part in the training came to have a better understanding of what person-centered care looks like. For example, taking an interest in the resident’s narrative in the “Photo” story could be seen as a concrete example of person-centered care. Another example of person-centered care is the simple act of enquiring into and calling a resident by their preferred name, which was identified by the PCA involved as “looking minor” but as having a major impact on both the resident’s socio-emotional wellbeing and the PCA’s job satisfaction. This latter example was also interesting as while calling an older adult a familial name (“Papa, Mama”) can be a sign of respect in many collectivist cultures (e.g., Middle Eastern and First Nation cultures; Sharifian, 2017), person-centered care requires actively identifying the name by which a resident prefers to be called.

The theme “Taking time” is also important in relation to person-centered care, given Anderson and Blair’s (2021) finding that a greater proportion of time spent with residents is associated with higher scores on a measure of person-centered care; and that measures of quality of life for residents increase with more observed positive behavior by staff toward residents, both physical and verbal.

On the topic of training, Anderson and Blair (2021, p. 12) noted that “staff ratings of the usefulness of training for their everyday work are associated with better staff treatment of residents.” They also commented that although formal qualifications do not necessarily translate into better quality of life for residents, it is important to evaluate training in light of integrating learnings into routine care practices, which was the focus of the MSC interviews with PCAs in the current project. While RTO students particularly emphasized that the training gave them new skills and insights into how to provide relational care to residents, RAC staff also reported benefiting from the training, including in being able to use these new tools and insights when working with residents living with dementia. The provision of relational care need not compete with meeting the practical demands of the PCA role. As Meagher et al. (2019, p. 37) observed in their review of the social and emotional support needs of older people using aged care services, “care quality is highly correlated with job quality, and . . . older people’s satisfaction with care is highly correlated with care workers’ job satisfaction.” Combining practical and relational aspects of care was shown in the Boxer story, where taking an empathetic approach and clearly demonstrating why the pants needed to be cleaned led to co-operation and agreement from the resident, who came to share the PCA’s view on the situation and what needed to be done.

It can be argued that the unique approach of The Little Things training comes from its conceptual underpinnings in the pragmatics of language use, or politeness theory as articulated by Brown and Levinson (1978), with its specific consideration of threats to face. This conceptual framework is particularly useful when considering the relational training of PCAs from culturally diverse backgrounds, as key concepts include the view that what constitutes a threat to face can vary by culture, and that being polite is more than following social protocols (e.g., using familial names) but involves engaging with others on a shared understanding of the social codes for interaction in a given situation (e.g., use of preferred names). This understanding can then lead to more confidence in interactions for culturally diverse PCAs and less chance of either themselves, or the resident they are caring for, experiencing discomfort, or feeling embarrassed or ashamed. Interactions can be improved in simple ways, such as softening requests by using indirect communication, as in the “Juice” story. These ways of communicating promote the dignity of the resident, by recognizing potential threats to face and avoiding these threats—in this case by offering choices.

Given examples such as these, it is possible that the MSCs associated with The Little Things training are not best captured by quantitative indicators (e.g., Likert point scales), but by using a qualitative methodology, such as the MSC, which is fine grained enough to capture the subtle but significant changes in people’s ways of being with others. Using the MSC methodology allowed identification of The Little Things training as an important contribution to PCAs’ training, with both personal and professional value. This is an important finding when considering the initial and ongoing training needs of PCAs, and consistent with previous qualitative research on identifying training needs of PCAs (Martyn et al., 2022).

Beyond the need for real person-centered care in aged care, the need for interpersonal training of the increasingly diverse aged care workforce is warranted by the expected increase in demand for staff due to the aging population in Western countries around the world. However, development of such training needs to occur alongside rigorous evaluation, both quantitative and qualitative, that includes giving a voice to as many PCAs as possible from diverse backgrounds (and to the residents they care for). The findings of the present study show that The Little Things program could be implemented widely to help more PCAs from culturally diverse backgrounds perform their valuable role in aged care with confidence.

Strengths and Limitations

A signal strength of the present study was the gleaning of insights into the benefits of the training from the various stories shared by the PCAs and RTO students using the MSC method. This method provided a more nuanced understanding of the experience and value of the training than could be gained through quantitative methods.

The first limitation was that, while efforts were made to keep the design of the intervention and evaluation components of the study separate, this was not entirely possible. The original research and implementation team comprised authors PJM and IH, who later participated in the MSC workshops; and the evaluation was led by author YW, who was aware of the progress of the project through attending the project reference group. However, external valuation based on outside values about what constitutes success is often not appropriate, especially when projects are participatory (Davies & Dart, 2005). Further, the workshop involved input from managers who were not involved in either the original research team or the evaluation team.

A second limitation, forced by the COVID pandemic, was the requirement that many of the individual interviews and the MSC workshop be held online. Using technology in MSC evaluation has several potential drawbacks: in particular, it can distort the data collection and group analysis processes. However, in the current project, there was no clear difference in quality between the narratives collected face-to-face and those collected online. Further, the MSC workshop proved engaging for participants (all of whom were in professional or managerial positions and familiar with, or learning about, the communication platform used) and so was able to achieve its aims.

Another limitation of the present study is the limited language skills of some of the respondents, several of whom struggled to find ways of expressing their views. While it can be argued that the MSC methodology used in this study gave a much-needed voice to PCAs from diverse backgrounds, the language barrier for some PCAs who participated only briefly in the interviews also needs to be acknowledged. There are widely recognized issues in including people from culturally diverse backgrounds in research (Shanley et al., 2013), and this can be particularly an issue in qualitative research that relies on participants being able to respond coherently to interview questions. In the current research we assumed that all participants would have sufficient English language skills to provide narratives, since they were all employed in residential aged care where English was the main language of communication or were Certificate III trainees, for whom some English proficiency was a prerequisite for entry to the course. Unfortunately, this assumption was not correct (which raises the question of what language skills are required to train and practice as a PCA). Given our assumption, we omitted a measure of English proficiency from the design of the evaluation.

Given the reliance of the MSC method on being able to collate and interpret narratives provided by participants and the limited English-language skills of some participants, there can be some question as to whether some stories edited by the researchers and included in the MSC workshop were distorted in “translation.” However, there was sufficient evidence from the stories collected that this appeared to be a minor issue, and that substantive aspects of the training were reflected in the stories shared both by PCAs from culturally diverse backgrounds and by Anglo-Australians. In the current study, there was an inherent but not fatal limitation in using the MSC with non-native speakers; that is, while not all stories could be included in the workshop, most were.

As with any qualitative research, alternative interpretations of narratives are always possible, and misinterpretation is especially a risk when participants are not fully fluent in the dominant language. While group-based analysis of narratives was intended to help overcome these possibilities, the risk of bias among the MSC workshop participants remained. For example, it could be argued that rather than increasing PCAs’ focus on relational care, the training made some PCAs more aware of how verbal strategies could be used to make residents more compliant in carrying out practical tasks (e.g., in the Boxer story).

Finally, the MSC method has been criticized for resulting in more positive evaluations of an intervention than otherwise might be obtained, since it may not include or prioritize the voices of critics of the intervention (Dart & Davies, 2003). Dart and Davies (2003) have acknowledged that the MSC is prone to different biases to those found in conventional methods of monitoring and evaluation and have recommended that it be used in combination with more traditional evaluation methods (as was the case here).

Conclusion

There is evidence that The Little Things training program adds value to how a PCA performs their role, particularly for individuals from culturally diverse backgrounds. The present study complements quantitative findings of the value of The Little Things by showing the subtleties of culturally diverse background PCAs’ experience of the positive changes in relating to older adults in their care brought about by this training. The implications of these findings are that relational-care training with PCAs from culturally diverse backgrounds is not only possible but desirable in developing their practice, and for improving both their experience in the workplace and the experience of the aged care residents they help care for.