Nursing, Care scares and Moral Panic.

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The number and tone of reports of poor quality care (e.g. Simmons 2011) especially, since the Mid Staffs NHS trust inquiry but by no means is defined by it, may be described as a moral panic and has been described as a crisis in care (Hari 2011, Phillips 2011a, 2011b) and “reveal a moral sickness in the professional ethic of nursing, and more particularly nurse training…” (Phillips 2011b) .These media reports over poor quality care (Marrin 2009, 2011, Shields et al 2011) and the identification of graduate nurses as folk devils who are “too posh to wash”, lead us to ask why this moral panic over graduate nursing has arisen?

 

A ‘moral panic’ is when a population feels the ‘social order’ is threatened, and that this threat is felt intensely, it is a certain reaction to a perceived social problem. A moral panic may be characterized by irrational, inappropriate overreactions to problems. Stanley Cohen (1972) applied the term to press reports and establishment reaction to the phenomenon of ‘Mods and Rockers’, a moral panic arises when:

 

“a condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests” (Cohen 1973 p9). The scathing criticism of graduate nursing in the press looks very similar to this sort of description. So, what societal values and interests are thought to be threatened by graduates?

 

The first aspect is that some feel a loss of ‘the proper place of women/nurses as mother archetypes’ which is part of the longer term process of female entry into the labour market and the break from domestic duties. Feminism has been blamed for this process (however the requirements of consumer capitalism and the need for labour has also had its effects).

 

The second is the ambiguities felt over the care of elderly people which increasingly has been seen to be the State’s proper role since the introduction of the Welfare State. Although the expressed social order demands that care of the elderly be done within families, the economy demands labour mobility resulting in geographically fragmented families unable to care for elderly relatives. The loss of the family wage and the rise of consumer culture also affects our abilities to care for both children and the elderly as both parents work. The actual social order is that elderly people are, en masse, in institutions and that allows us to abrogate our responsibilities. Although no one expresses a wish to be in a nursing home, no-one either wants (or is able) to take responsibility for elder care.

 

The third aspect is that body work which involves intimacy, closeness as well as dirt and disgust, is again seen as female caring work which does not attract any social value or support beyond expressions of stoic heroism on behalf of carers.

 

Graduate nurses challenge these conceptions by being women who are educated, who work and expect like any other professional to be rewarded for their efforts, there is then a cognitive dissonance between on the one hand a vision of nursing as self sacrificial angels and as professionals requiring proper education and reward as professionals. One way to solve this dissonance is to reframe professional nursing, i.e. ‘train’ them in hospitals (putting them in their ‘proper place’).

 

However, the place of women, and women as nurses, the ambivalence towards care and its meaning, the increasing marginalisation of the elderly and their devaluing may be manifestations of society’s turn from solid to ‘liquid modernity’ (Baumann 2000). Social values, aspirations and expectations are played out within the themes of globalization, individualization, marginalisation, poverty and consumerism. These are the actual social threats that this moral panic cannot actually name and identify. ‘Folk devils’ have to be found to explain these new forms of alienation. Poor care has been around as long as there have been carers, and so we need to be careful not to argue that liquidity causes poor care, rather it may the case that liquid social conditions predispose individuals to perform in particular ways and for their actions to be interpreted in particular ways. The folk devils are in, this instance, graduate nurses. However, blaming nurses refocuses attention away from more difficult problems and gives easy solutions (‘return training to hospitals and all will be well’).

 

Liquid modernity, according to Baumann, involves community fragmentation, eroding social bonds, atomized relationships and individualistic expectations all in the context of the globalization of capital and markets which dislocate communities. Workers have to respond to calls for mobility and flexibility or face redundancy. Communities struggle to reconcile competing demands especially with the increasing numbers of elderly people and costs of care. Nurses and midwives find themselves caught between all of these competing demands unable to make the links between their individual experiences and larger social conditions,

 

If only one nurse abuses a patient we should properly look to the character of the individual nurse for reasons.  When cases of reported abuse become legion then the personal troubles of the patients should be seen in the context of the public issues of society. To fully comprehend the position of the abuser we need to address their personal biography and history and the relationship between the two in society. Anyone wishing to analyze why there is poor care needs to avoid simplistic knee jerk moral panic type reactions and grab the idea that nurses can understand their experiences and gauge their fates only by locating themselves within their period, that they can know their  own lives only by becoming aware of all those nurses in the same circumstances. Focusing on the personal accountability of care staff without addressing the structural conditions in which they work simply will not do.

 

So what then is the answer?

 

Care has to be really valued, and in current society the main way value is ascribed is to place a monetary value onto it and bring it centrally into business planning. Therefore the cost of care has to be brought into all accounting. Capitalist production currently does not take into account the care (and environmental) costs that society bears for that production. However caring still has to be done or else production cannot continue in its current form. This is not a new argument, feminists and environmentalists have been arguing this for years. If society wishes to value care then it has to pay for it. That means increasing the number of staff and paying them a competitive wage so that good quality staff are educated, retained, supervised, developed and valued. Or, as Sue Gerhardt (2010a) agues we should refocus on caring as a real social value and perhaps introduce a ‘caring wage’ (2010b) say £12,000-£16,000 per year? Society has to value care with more than lip service and the stoic angels tag, but in the current economic setting social values are not strong enough to ensure we will do this.

 

 

 

 

 

 

 

Bauman Z. (2000) Liquid modernity. Polity. Cambridge.

 

Cohen, S. (1973). Folk Devils and Moral Panics. St Albans: Paladin, p.9

 

Gerhardt S. (2010a) The Selfish Society. How we all forgot to love one another and made money instead. Simon and Shuster. London.

 

Gerhardt S.(2010b) The Selfish Society. RSA events. 22nd April. http://www.thersa.org/events/audio-and-past-events/2010/the-selfish-society

 

Hari, J. (2011) The plan to resolve our care home crisis. The Independent January 26th http://tinyurl.com/5ugyond

 

Hawken P (1994) The Ecology of Commerce. Harper Collins. London

 

Marrin, M. (2009) Oh Nurse, Your degree is a symptom of equality disease. The Sunday Times. November 15th

 

Marrin, M. (2011) Our flawed uncaring NHS is a self inflicted wound. The Sunday Times. May 29th

 

Phillips, M (2011) The moral crisis in nursing, voices from the wards. Daily Mail. October 21. http://melaniephillips.com/the-moral-crisis-in-nursing-voices-from-the-wards

 

Phillips, M. (2011) How feminism made so many nurses to grand to care. Daily Mail. October 17. http://melaniephillips.com/how-feminism-made-so-many-nurses-too-grand-to-care

 

Shields, L., Morrall, P., Goodman, B., Purcell, C. and Watson, R. (2011) Care to be a nurse? Reflections on a radio broadcast and its ramifications for nursing today. Nurse Education Today. doi:10.1016/jnedt.2011.09.001

 

Simmons, M. (2011) Poor Nursing care. NursingTimes.net. 4th July. http://www.nursingtimes.net/poor-nursing-care/398.thread

 

 

 

leadership for the future

This paper is for spanish nurses on a leadership course but has general application:

“Considerable evidence suggests that neocolonialism, in the form of economic globalization as it has evolved since the 1980s, contributes significantly to the poverty and immense global burden of disease experienced by peoples of the developing world, as well as to escalating environmental degradation of alarming proportions. Nursing’s fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order”. (Falk-Rafael 2006)

 

The theories and issues so far covered in this module are focused on the individual (micro) and organisational (meso) level of analysis. Nurses are asked to examine their personal resources and the culture of the clinical setting and the hospital environment in which they work. The immediate focus is on patient outcomes: their safety, their recovery, their dignity and their comfort. Many of the policy drivers for critical care rightly ask us all to consider the patient’s journey, to see the issues from their perspectives as well as from our own.

 

You have been invited to consider whether transformational leadership is a style fit for clinical practice, you have been invited to consider how interpersonal and interprofessional relationships affect your work, you have been invited to consider how we add value in a public sector organisation, you have been invited to consider applying CQI as a process in your work.  

 

But you have not been invited to take the next step: The macro analysis.

 

A macro analysis asks you to see beyond the individual, the clinical unit and the hospital. It asks you to consider wider socio-political issues that impinge on public health and well being. Critical care rightly focuses on the seriously ill individual and the skills and competencies developed for nurses reflect that. However, Nursing is an ethical endeavour, your exercise of leadership reflects your ethical positions. The decisions you don’t take may be as important as the decisions you do.  The world view you ascribe to helps to create the world you live in. You have an opportunity for just a moment to raise your eyes above the bedside and think about your vision for the future.

 

A good deal of discussion in leadership theory is about vision, that leadership is a role, it is a process and can be exercised by anyone.  Being a ‘leader’ is a post holder (chosen, elected , appointed), but a formal post may or may not exercise leadership. So I wish to ask, what are you leading for, for you are all potential leaders regardless of the formal title or post you hold. What is your vision? What are your ethics? What do you care about?

 

Sarah Parkin (2010) argues that much of leadership education does not clearly see the impending crises of unsustainable economic, business and political practice, has failed to see the wider picture and has failed to ask what is leadership for?

 

We know we live in a messy world (Peccie 1982, Morrall 2009). The financial crisis that started in 2008 continues prompting the indignados movement.  Spain has a 46.2% under 25 unemployment rate where young educated people argue:

 

“juventud sin futero, sin casa, sin curro, sin pension, sin meido.” (The Economist 2011).

 

We know that economic inequality has direct health effects (Marmot 2010, Wilkinson and Pickett 2009). We know what the under 5 mortality rate in many countries is still far above the stated target of the Millennium Development Goals (MDG 4). The WHO (2008) supports the ‘social determinants of health’ approach which links social, political and environment issues with human health. Climate change is the biggest threat to public health and security in this century (Costello et al 2009, BMA 2008, 2011, Goodman and Richardson 2009, Goodman 2011).

 

These issues, Parkin argues, require leadership as “positive deviancy”. A positive deviant is:

 

“a person who does the right thing for sustainability, despite being surrounded by the wrong institutional structures, the wrong processes and stubbornly uncooperative people” (2010 p1).

 

There is an urgent need for healthcare professionals to address the sustainability of current politics, economics and social practices (Goodman 2011). The exact nature of that response is down to individuals. However, without some macro analysis we are in danger of leading ourselves into the dark. This then leads us to ask about out ethical responsibilities on a globalised world.

 

Nurses’ ethical responsibility in a globalised world?

 

Globalization results in large capital flows, labour movement and displacement and the increasing dominance of TransNational Corporations (TNCs) on economic, social and political life. The demise of state power for the public good and its alignment with finance capital (Harvey 2010, Crouch 2011) – results in its increasing withdrawal from public services in many European countries. The TNCs and ‘the markets’ are two voices guiding politics. The current Eurozone crisis illustrates how politicians have to create polices that the international financial institutions feel are acceptable to them.  Collier (2008) suggests that we have a bottom billion stuck in poverty, and the WHO acknowledges wide health inequalities. Even for the Rich, threats to survival are not domestic but global. Perspectives are changing from local to global, the ethics of healthcare thus need to be discussed in this context. The WHO’s Millennium Development Goals also set a global policy framework. There is thusa need for another voice to defend global public goods such as health.

 

Ethical practice (source Austin 2008):

 

Paul Ricoeur (1992) suggested that ethics are about “aiming at the good life”, and so if this is the case we ought to consider the good for all. If everyone has a right to the opportunity for a good life, what should the Nursing response be? 

 

Consider the codes of Ethics that govern nursing practice. Where are they and what do they say?

 

Professional ethics:

 

   http://www.icn.ch/about-icn/code-of-ethics-for-nurses/  International Council of Nurses. Code of Ethics for Nurses.

 

Acting Ethically as a nurse in a global community requires a need for transformative thinking and leadership as positive deviance. 

 

 

My frame of reference is that healthy lives depend on a healthy socio-economic and physical environment as outlined in the Social Determinants of Health approach (WHO 2008) which has as its outer layer in the model ‘general socioeconomic, cultural and environmental factors’, i.e. social and environmental structures. Thus, I largely agree with Peter Morrall (2009) who argues that patterns of illness and disease are largely determined by issues of social structure and increasingly physical environments. Social structures protect some while damning others to misery and poverty as evidenced in the inequalities in health literature. The affluent even in poor countries and difficult environmental conditions live in ‘safe’ enclaves where they can ensure clean water and a ready supply of food, even in famine stricken countries, money buys food. However, even the affluent will be affected by global changes in certain key environmental limits.

 

The key power relationships operating at present is the hegemonic stranglehold of advanced consumer capitalism in which the richest 2% own 50% of the world’s wealth (Davies et al 2006). Many do not understand or recognise the notions of limits, while others put undue faith on the resourcefulness of humanity to solve the problems but to do so within the frame of reference of ‘business as usual’ unaware that their selves are interconnected and interdependent within a much wider framework of meaning.

 

Thus there is a need to transform thinking. Currently leadership is the problem not the solution because we are not asking what we are leading for.

 

To encourage and transform leadership there is a need to engage in provocative pedagogy whereby we engage in intellectual critique through being challenged with provocative positions. We need a sociological imagination to connect personal troubles with public issues, to fully understand their personal biographies as related to wider social forces at this point in history.

 

Medical and nursing disciplines cannot be immune from this process. It is not enough to learn how the body works and what to do when it goes wrong. This is navel gazing of the worse kind. Many doctors and nurses have for a long time been pioneers for social action, acting on behalf of the poor, weak and vulnerable. That is their ethic. That has been their historic mission, the problems of this messy little world may not mean a hill of beans to many but without a reawakening of consciousness and a reconnection of self to others, which includes the biosphere, the future looks grim. Peter Morrall (2009) has argued that we as health professionals and/or academics have an ethical responsibility to take individual, collegiate, and organisational action with regard to the social ills which affect human health and happiness.

 

However, taking a stand is hard. Ethics is hard.Ethics requires thinking. We may be the only sentient being on the planet who can think and reflect on our existence and the search for ‘truth’  It may be that we have a special responsibility to think about our decisions and why we make them. Damon Horowitz has recently argued (2011):

 

Not only can we think,we must.Hannah Arendt said,“The sad truthis that most evil done in this worldis not done by peoplewho choose to be evil.It arises from not thinking.”That’s what she called the “banality of evil.”And the response to thatis that we demand the exercise of thinkingfrom every sane person

 

But this may lead to ‘Moral distress’ and Moral responsibility – by understanding the disparities in health if we have responsibility what does that mean? We may provoke moral distress, but then what?

 

 

Austin, W. Chapter 3 in Tschudin, V. and Davis, A. (eds) (2008) The Globalisation of Nursing. Radcliffe. Oxford.

 

British Medical Association (2008). ‘Health professionals taking action on climate change’, http://www.bma.org.uk/ap.nsf/Content/climatechange

 

British medical Association (2011). The health and security perspectives of climate change. October 17thhttp://climatechange.bmj.com/statement

 

Collier, P. (2008) The Bottom Billion, OUP. Oxford

 

Costello, A. et al  (2009). Managing the effects of Climate change. Available online at http://www.thelancet.com/climate-change

 

Crouch, C. (2011) The strange non death of neoliberalism. Polity Press

 

Davies, J.,  Sandstrom, S., Shorrocks, A., and Wolff, E. (2006) The world distribution of household wealth. December. UNU-WIDER http://www.wider.unu.edu/events/past-events/2006-events/en_GB/05-12-2006/

 

Economist, The. (2011). Left behind. September 10th. http://www.economist.com/node/21528614

 

Falk-Rafael, A. (2006) Globalization and Global Health: Toward Nursing Praxis in the Global Community. Advances in Nursing Science: January/March 2006  29 (1) p 2-14

 

Goodman B., Richardson J. Climate Change, Sustainability and Health in United Kingdom Higher Education: The Challenges for Nursing in: Jones P., Selby D., Sterling S (2009). Sustainability Education: Perspectives and Practice Across Higher Education. London, Earthscan.

 

Goodman, B. (2011). The need for a sustainability curriculum in nurse education. Nurse Education Today [online] http://www.nurseeducationtoday.com/article/S0260-6917(10)00262-5/abstract 14th January 2011

 

Harvey, D. (2010) The enigma of capital and the crises of capitalism.

 

Horowitz, D. (2011) Calls for a moral operating system. TED.com http://www.ted.com/talks/damon_horowitz.html?utm_source=newsletter_weekly_2011-06-07&utm_campaign=newsletter_weekly&utm_medium=email

 

 

Marmot, M. (2010) .Fair society, Healthy Lives. The Marmot Review. Strategic review of health inequalities in England post 2010. http://www.marmotreview.org

 

Morrall P (2009a). Sociology and Health. London: Routledge.

 

Parkin, S. (2010). The Positive deviant. Sustainability leadership in a perverse world. Earthscan . London.

 

Peccie, A. (1982). One Hundred Pages for the Future: Reflections of the President of the  Club of Rome. Futura books.

 

Ricoeur, P. (1992) in Austin (2008) op cit.

 

Tschudin, V. and Davis, A. (eds) (2008) The Globalisation of Nursing. Radcliffe. Oxford.

 

Wilkinson R and Pickett K (2009).  The Spirit level. Why equality is better for everyone. Penguin. London.

 

World Health Organisation (2008). Closing the gap in a generation. Health equity through action on the social determinants of health.  WHO.