Month: January 2015

‘Moral Failing’ in Nursing?

The NHS is often in the news, and not always for the right reasons. Health care staff are working hard to keep the ship afloat but do so often at great personal cost due to stress and burnout. Unison (2014), in their report ‘Running on Empty. NHS staff stretched to the limit‘ outline the reported conditions in which NHS staff are giving care. It is not good reading. Two quotes illustrate the situation:

“Every day we struggle with beds . Constant harassment from managers to free beds and discharge patients, sit patients out of bed, etc . There is no time for anything meaningful. Managers are obsessed with targets . Targets don’t measure quality of care .”

and

“On occasions, staffing levels are bordering on dangerous.  We are in a Mid Staffs situation and I don’t believe we are the only ones.”

In 2013 the RCN published a similar report ‘Beyond Breaking Point‘ in which it is suggested that patient care is under pressure from nurses’ stress.

However, Dan Poulter of the coalition government have argued that although the NHS faces challenges, the “health service is bearing up and treating people very well“. This may well be true. The quality of care may well be good to excellent. The King’s Fund suggests:

“…in broad terms the NHS has continued to provide services to a growing population and to maintain the quality of those services. However, there is deepening pessimism about the ability of the NHS to make ends meet financially, particularly in 2015/16”.

Talk about crisis may be premature, but it may well be the case that patients are getting good care despite, and not because of, the structures and finances to support staff giving that care. patients may be getting care at the expense of the wellbeing of some staff.

This may well have always been the case. One long standing description of nursing may not have been helpful in the past, but due to changed circumstances, may now have become an out dated and indeed injurious conception of what nursing now is. This description of nursing as individual moral work, or perhaps otherwise called a ‘vocation’,  is under now under continued scrutiny.

Much has been written about Mid Staffs and perhaps this is fading into history. However, for nurses the underpinning pressures on them remain. Michael Traynor (2014)  in a recent article highlights one of those pressures: the identification of nursing as ‘character based moral work’. This is reflected also in the United States in that some states require assesment of ‘good moral character’ for licensure to practice. In the UK the purpose of ‘values based recruitment‘ is:

“…to ensure that we recruit the right workforce not only with the right skills and in the right numbers, but with the right values (my emphasis) to support effective team working in delivering excellent patient care and experience”.

There is nothing intrinsically wrong with this approach. In fact I would hope that all health care staff, and indeed all of us, come to work with ‘good moral character’ while holding the appropriate values. This applies to a taxi driver as well as to politicians.

For nurses, however this emphasis on their work as ‘character based moral work’, supported by University recruitment that focuses on those with a ‘caring orientation’,  may operate to deflect analysis of the systems of work that result in ‘cognitive, professional, bureaucratic and work’ pressures (Traynor 2014) which may, for too many, result in stress and burnout. Failings in care are also seen in these terms – i.e. that of the individual failure of the moral character of the nurse.

Traynor’s argument is that:

1.  Nursing failures are possibly an inevitable consequence of work in health systems  under pressure.

2, Nursing is often viewed as primarily ‘character based moral work’, to an extent not applied to other occupations.

3. The profession focuses on recruiting those with a caring orientation but does not equip these new recruits with an adequate understanding of the causes of inadequate practice.

4. This leads to acquiescence to poor standards and hinders the development of ‘critical resilience’.

Student nurses learn about the legal and ethical basis for care, they study leadership and management theory, they address quality enhancement as well as developing clinical skills. They do so often without a critical theory of the context of the care system they enter and often face moral distress when the care they want to give is bounded by the myriad pressures they and their mentors face in reality. Instead personal accountability is stressed and their individual moral character is scrutinised. Before they can register a declaration of good character has to be signed. All of this is blind to the reality of practice.

Perhaps it is time to reexamine the chimera of ‘character based moral work’, divest ourseleves of this misleading description of the basis of nursing practice and instead use our sociological imaginations to develop political and critical resilience in student nurses.

I may warm to this theme.

Narrative medicine? Listening to the patient’s story and emotional response: Anne the ‘anorexic’.

Listening to the patient’s story and emotional response: Anne the ‘anorexic’.

In this brief paper, I discuss the importance of the patient’s story and having the space to listen to it.

The way doctors come to their diagnoses, how they listen to patient’s stories, how they decide what to treat, is not a straight forward process though it might seem so. Take a history-perform a physical examination-order tests-analyse results-diagnose-treat-evaluate treatment. It looks linear. It is supposed that the hypothetico-deductive method accurately describes this thinking. However, the objective gathering of data, the analysis of that data to produce a hypothesis, the testing and revision of that hypothesis and subsequent diagnosis could be more an objective academic description of a process rather than an accurate description of what happens in actuality.

 

In addition, medical (and nursing) students are taught increasingly using algorithms, protocols and preset guidelines and decision trees. Evidence based practice in addition supports decisions based on statistically proven data which, while providing sound data regarding populations, cannot account for the idiosyncratic individual patient. Bayesian analysis underpins this type of approach (gather data – hypothesise – assign statistical probabilities – calculate likely diagnosis).

 

Now that nurses are beginning to undertake clinical consultations and diagnosis, the errors in thinking, the ‘cognitive biases’ that doctors are open to, equally apply.

 

Therefore it may be useful to think about our ‘ways of thinking’ in addition to our ‘ways of knowing’. That is to say that in or empirical, aesthetic, ethical, intuitive and social domains of knowledge we may engage in disordered thinking in order to come to empirical, aesthetic, ethical, intuitive and social decisions.

 

According to Groopman (2008) Medical errors result more as a result of ways of thinking rather than technical errors (prescribing the wrong dose of drug for example).

 

One good way to get a grip on this is examining actual cases. The following is from Jerome Groopman’s (2008) ‘How doctors Think’:

Anne Dodge.

Over a 15 year period Anne had seen many doctors. Her problems started with food, experiencing a twisting pain in her stomach after a meal. A visit to the family doctor, resulted in a visit to the psychiatrist with a diagnosis of anorexia nervosa.  Following that Anne had seen:

 

  1. A GP specialising in eating disorders.
  2. Endocrinologists
  3. Orthopaedists
  4. Haematologists
  5. Infectious disease specialists
  6. Psychologists
  7. Psychiatrists

 

Treatment had included four different antidepressants, weekly talking therapy and nutritional assessment monitoring calorific intake.

 

Osteoporosis developed, a hairline fracture of a metatarsal, and a failing immune system resulting in a series of infections including meningitis. Anne was hospitalised 4 times in 2004 in an attempt to gain weight under supervision. However the more she ate the worse she felt. Finally her doctor decided she had Irritable Bowel Syndrome (nausea, vomiting, intestinal cramps, diarrorhea). Despite eating 3000 calories per day she lost weight, which the psychiatrist interpreted as her not telling the truth about intake, consistent with psychological stress and anorexia.

 

The past 12 months saw a deterioration. Red blood cells and platelets dropped dangerously, she felt ill, bone marrow biopsy showed few developing cells. Haematologists put this down to nutritional insufficiency.

 

Finally she was seeing Dr Falchuk, a gastroenterologist.

 

Would he be any different confronted with a very long history, diagnosis and symptoms consistent with IBS, deteriorating mental health and anorexia? The referring doctor implied that he should examine (again) her abdomen and confirm IBS and its treatment.

 

However, his first approach was to question, listen, observe and to think differently. It was Anne’s words which led to the correct diagnosis, not the tests, procedures and scans, language being the bedrock of clinical practice.

Falchuk first noticed body language and observed in Anne:

 

  1. She looked emaciated and haggard, faced creased with fatigue, hands clasped together – he thought how timid she looked.
  2. Beaten down by suffering, she needed a gentle approach that would draw herself out.

 

In the consultation, Falchuk put aside the pile of case notes and simply asked Anne to go back to the beginning, to tell him about when she first felt ill. He asked for her own story in her own words. Anne told her long story all the while encouraged to continue by Falchuk. Then he asked for specifics about her recent attempts to gain weight and what happens after each meal. Anne had felt she had already explained this before to her doctors but now had the time to express her experience. In this encounter the emotional response by Falchuck was instrumental in the unfolding of her story. Falchuk undertook a physical exam but not just of her abdomen; following her story he looked for clues in her mouth and nails,  and her loose stool that remained in her rectum.

 

Not convinced her symptoms were down to IBS or anorexia he ordered bloods and an endoscopy. He believed that indeed she was taking in 3000 calories but that something prevented digestion, hence the weight loss.

 

Falchuk’s consultation and tests revealed coeliac disease. Anne soon gained 12 pounds, the IBS symptoms disappeared. Anne did have an eating disorder but she also had coeliac disease commonly thought to begin in childhood.

Falchuk explained that a maxim he used was that:

“ if you listen to the patient, he is telling you the diagnosis”

 Technology he argues can take you away from the patient’s story. He argued that the “picture didn’t fit”, Anne’s story did not fit the known facts about her medical condition.

 

Debra Roter and Judith Hall have researched doctors’ communication and point out that doctors need to ‘wake the patient up, so that they feel free to seek and enter into dialogue’. If the patient is inhibited or cut off or constrained down one path something vital could be missed. It has been noted that doctors interrupt within 18 seconds of the patient’s story. Falchuk gave Anne more than 18 seconds.

Falchuk began with Anne with open ended questions, responding to the emotions of his patient. Without attending to her emotional state her story would not have emerged. If one is sure of a diagnosis then closed questions can get you to your end point quickly. This was not the case with Anne. We need to reflect that in our initial encounters with patients presenting with minor illness and injury that the sure diagnosis may lead us into closed questions, non attendance to the emotional state of the patient and the potential for missing a vital clue that indicated something important for the patient. Hall argues that patients can easily pick up how doctors are feeling about them and in consultations those feelings can negatively impact on how the patient expresses themselves.

 

The cognitive error was to put Anne into a narrow frame (IBS, Anorexia) and information that did not fit that frame was ignored or not even elicited due to consultation style and over reliance on known facts.

 

Conclusion.

 

Although we do not see complex cases like Anne every day, we still need to listen to the patient, as they will pick up on how you are feeling toward them. This will influence the direction of the consultation and the sort of questions asked and the answers given. The manner of the consultation will direct the result. The technology and investigations are adjuncts. A sure diagnosis may mislead. The fact that we see many ‘minor cases’ may militate against developing this consultation style at all and prevent us  recognising this error in thinking when we may need it most.

Reference

Groopman, J. (2008) How Doctors Think. Mariner. Boston.

See also: http://www.happinessinthisworld.com/2009/04/26/when-doctors-dont-know-whats-wrong/#.VLPE1yusV8E

 

Should we laud the rich as tax heroes?

Boris Johnson, aka ‘top cornflake’, argued in 2013, that the top 1% contributes almost 30% of income tax and that top 0.01% contributes 14% of all taxation. However, as income tax is 26% of all government revenue (NI raises 18% and VAT raises 17%) this equates to 8% of all government revenues. Therefore his claim that top 0.01% contributes to 14% of all taxation is just wrong. The top 1% actually contribute 8% of all government revenues.

In making this claim he is arguing we should thank the rich for their contribution:

“I proposed that we should fete them and decorate them and inaugurate a new class of tax hero, with automatic knighthoods for the top ten per cent”. Of course this is jest and rhetoric; surely he cannot be serious and muses on this as bit of lefty baiting?

He creates a value system, which results in lauding the rich for taking more than they ever have done, by trying to claim they are contributors beyond calling enough to warrant knighthoods. I don’t think giving 8% of all revenue is anything to be proud of, especially when the gap between the 99% and the 1% is so large. This is much, much worse if we focus on the 0.1%. The disparity within the 1% is breath-taking.

I would invert that value system and call it a self-serving  justification for the biggest income and wealth grab we have seen since Edwardian times.

This is mere number crunching, the actuality is more relevant. People’s lives are affected not by overall tax rates quoted by Johnson but by their absolute incomes and thus the % paid as a proportion of that income. If we focus on this, then we find that the poorest 20% pay 36.6% of their income in taxes, just a tad more than the top 1% who pay, 35.5% (Dorling 2014 p162). Tax heroes? How heroic is it to pay about the same proportion of your income as the bottom 20% do, when what you have left is riches beyond the dreams of avarice?

You might want to consider that 36% of a low wage leaves much less than 35% of a very high wage.  Food, petrol, utilities, clothes still costs the same amount whether you are rich or poor. If I earn £10,000,000 pounds pa and am taxed at 80% that leaves a ‘mere’ £2,000,000 to live on. Poor me, some tax hero!

See: http://www.thersa.org/events/audio-and-past-events/2014/inequality-and-the-1

Dorling D (2014) Inequality and the 1%. Verso. London

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