Care, Compassion and the Social Structures of Oppression
Nurses are asked to consider dignity and compassion as nursing issues. However if media reports such as ‘my husband died like a battery hen in hospital’ are correct , and there are far too many to be dismissed, certain practices can squeeze compassion out of nursing care. We therefore need to be critically self-reflective and critically thinking (Morrall and Goodman 2012) of the ‘social structures of oppression’ (Harden 1996). Jeremy Hunt has recently described ‘the normalisation of cruelty’ in NHS organisations. If this is correct we need to analyse why this might be so. However, and accepting that there is poor care, this phrase is part of a campaign of criticising public sector organisations in order to soften up the public mood for privatisations. It is part of this wider public relations exercise. That being said, we cannot overlook the real pain and suffering of patients as being only down to ‘them’ (whoever ‘they’ may be).
Thus, it is necessary for nurses to reflect upon the reasons we see such poor quality care. This is not just or only a case of failing, uncaring individuals which require calling them to account, although there is truth to this. There will always be individuals who ‘do not give a stuff’ and see care work as only a means to an end, i.e. the pay.
Up to the point when the struggle for material conditions no longer becomes an issue, money is an extrinsic reward and motivator. The fundamental basis of most work in a capitalist system is the ‘cash nexus’ i.e. the starting point for work is the pay. This is an extrinsic motivator. Take away this extrinsic motivation, and then take way all other intrinsic motivations (to care, be compassionate, to make a difference, because it is fun….) work then becomes meaningless. Many nurses and care assistants are relatively low paid and this is their sole extrinsic motivator. Nurses don’t get much in the way of other extrinsic motivators such as status or privileged/free access to important goods and people (perks). Thus to keep working they rely on their intrinsic motivators just mentioned.
To demonstrate the importance of pay, just consider how many nurses would stay at their posts if they a) won the lottery b) came into a decent inheritance c) were independently wealthy. There would no longer be the extrinsic reward and motivator to work. Would any intrinsic motivator that one still has (the sheer love of caring) still make one go to work? So let’s be honest with ourselves first. Without pay many of us would not nurse. That being said nurses do then bring into their daily lives their intrinsic motivators. Then they are paid just enough to care, just enough so that any innate compassion can be exercised. However that is a fine line.
Nursing work is often dirty ‘body work’ that few would willingly take on just for the love of it. The ’emotional labour’ involved also takes its toll. However, there is still a caring ethic underpinning nursing and most nurses wish to be compassionate and nurse because of the pay yes, but also because they want their work to ‘mean something’. This compassion can be trampled upon by the context in which it has to operate – job losses, poor staffing levels, poor skill mix, lack of clinical supervision, poor access to professional development, lack of social status and esteem, patient complexity and consumerism, hierarchical, patriarchal and bureaucratic managerialism to name just a few oppressive social structures. So, in essence, poor care is a political and social issue not just an individual one. Too often we pick on the failing individual nurse(s) when we should be stripping away the layers of context which promotes uncaring attitudes or does nothing to weed it out. The Francis Report into Mid Staffordshire NHS Trust, for example, shows certain management cultures that hardly supported good care, and the Margaret Haywood case shows what happens to whistleblowers.
However, we also need to consider the fact that within similar organisations experiencing the same funding and staffing issues, why there are differences in compassion and care? What are some ward managers and individual nurses doing that demonstrates that care is not being compromised? I suspect there is a complex interplay of various social and local factors which play out in hospital and care homes that results in horrific experiences for one and superb care in another. I also suspect that articulate, confident, intelligent nurses give high quality care despite and not because of the social and organisational contexts they find themselves. As nurses and care assistants in the NHS come under increasing pressures, the bad apples will have more space to operate and compassion fatigue could set in even further.
So students of nursing and nurses are being exposed to savage criticism of nursing care, we have to be honest and say that in some cases this is justified. However this is complex and the analysis of the antecedents of poor care must take us beyond simply blaming failing individuals. Indeed a recent, February 2013, Nursing Times survey indicates that nearly 50% of staff consider ward staffing levels to be dangerous. This is part of the context ‘failing’ individuals find themselves.