Tag: Compassion

Too posh to wash? Failures of the governing, managerial and political classes

Too posh to wash? Reflections on the future of Nursing.

 

When…only one man is unemployed, that is his personal trouble, and for its relief we look to the character of the man, his skills and his immediate opportunities. When…15 million…are unemployed, that is an issue, and we may not hope to find the solution within the range of opportunities open to any one individual…Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals”. (C Wright Mills – The Sociological Imagination p9).

 

 

In the many contributions to the debate about poor quality care, there is often a distinct lack of a sociological imagination. While individuals can be rightly criticised for giving poor care, the antecedents are to be found beyond the personal trouble of individual nurses and their patients, and can be classed as a public issue: that of the political, social and economic failures of the governing, managerial and administering classes over the past few decades.

 

‘Too posh to wash’ is the title of a recent publication on the condition of nursing in 2013 and reflects newspaper headlines and the Health Minister, Jeremy Hunt’s, call to student nurses in March 2013. In it there is a range of contributions from various practitioners and experts on the delivery of care in the UK. They were asked to address various questions:

 

1. Why do we have lapses in nursing care and what needs to be done to prevent poor care back into caring?

 

2. In striving for professionalism have we over qualified yet undertrained today’s nurse? Are they too posh to wash? What mechanisms and support systems need to be in place to ‘bring excellence’ back into the profession?

 

3. Has the role of the nurse leader been devalued? Has respect for their knowledge and expertise and a desire to emulate them decreased?

 

4. Why have boards within both NHS and non-NHS organisations appeared to have failed to deliver the expected improvements in quality of care? Are board members unaware of the standards on their wards or in their care settings?

 

Various issues and solutions were raised but the answer to the title appears to be: “no”, students are not too posh to wash.  The myth of a golden age was shown to be just that – a myth. Menzies Lyth’s 1960 paper was quoted and is still worth a read today. I would also refer to Kath Melia’s work around the challenges students faced nearly three decades ago.

 

Among the normative statements made, i.e. what nurses ‘ought’ and ‘should’ do, there was some attempt at analysis of underlying reasons for poor care. This included societal attitudes to ageing and caring, and technology and is affects on communication. There was no call however to return to apprenticeship training outside the University. This accords with the findings of the Willis Commission (2012).

 

What was striking was the almost passing references to systemic failures within the NHS around the structures for providing care. These failures are the responsibility of the governing political and managerial classes who are charged with running the NHS. While we are acknowledging ageing populations, increasing frailties and complex care needs, there is a a requirement to examine the context of care. To examine what structures have been put in place to deliver care to increasing numbers of frail elderly people in acute hospitals and care homes. Student nurses in particular are placed in clinical practices which are not conducive to compassionate care, and are often the least equipped to understand, analyse and bring about change.

 

Universities can support the development of critical thinking and underpinning knowledge but are almost powerless to affect this care context in which students find themselves. No amount of curricular changes emphasising compassion and caring will work if students continue to experience Melia’s 1984 and Lyth’s 1960 descriptions of the care environment.

 

Menzies Lyth (1960) argued that nurses experienced high levels of anxiety due to their work and that there was an absence in the hospital of any mechanism through which to ‘positively help the individual confront the anxiety provoking experiences’. The result was a set of defensiveness techniques including the splitting up of the nurse-patient relationship. A more recent research report (Hillman et al 2013) also report ‘defensive practice’ resulting in an ‘us and them’ subject position regarding their patients as nurses felt the pressures of litigation, complaints and the pressing need to meet the managerial requirements of the organisation.

 

Melia (1984) outlined two competing ‘segments’ – the ‘educational’, focusing on learning, and the ‘service’ which focused on ‘getting the work done’. In learning to ‘fit in’ students experienced a transient approach to nursing implicitly supporting a lack of commitment to nursing as an occupation. This is mirrored in a 2010 study of Norwegian students in which it is argued:

 

“While clinical practice often has focus on practical problem-solving and procedures, the college tends to focus on abstract theory. Both of these promote the privatisation and neglect of the students’ experience of care. The paper concludes with a call for teaching and learning strategies targeting the use of nursing students’ personal experience of care”. (p73 Solvoli and Heggen 2010).

 

So, no ‘golden age’ then or now.

 

In the 2013 ‘Too posh’ document, three commentators pointed out the critical place that clinical practice experiences have which implicitly build upon Menzies Lyth and Kath Melia.  Professor David Sines argued that there needs to be:

 

 

1. dynamic placement opportunities for students that expose and challenge them to confront the complexity of health and social care, within, between and across clinical care pathways, supported by a curriculum that is ‘wrapped around the patient’s/user’s real experience and journey’;

 

2. robust, enhanced and effective mentorship and preceptorship partnerships with our Trusts;

 

These 2 ambitions will not be achieved in care environments where there is poor skill mix; care given by care assistants who may be poorly supervised and trained; poor staff-patient ratios and minimal professional support and development. Sines goes on to argue:

“Above all our next generation workforce requires access to expert mentorship and role models to nurture and inculcate excellence in practice and resilience in attitude to deliver optimal standards of care at all times, turning each patient encounter into a learning opportunity that leads to sustainable excellence” (p15).

 

Again this is a key issue: ‘Access to expert mentors’. Far too many students report the lack of both access and the quality of support in this area. Therefore this may sadly, in the current context, be too idealistic. This might be born out by Bradbury Jones et al (2011) who reported that not all students have a positive experience:

 

“Unfortunately there were many examples of disregard and disrespect of students as learners. Lack of encouragement and responsibility were significant issues and this had a negative impact on students’ knowledge and confidence. These findings are consistent with nursing literature in terms of lack of support and encouragement and specifically, lack of interest in learners (Lindop, 1999). The findings also mirror those of Levett-Jones and Lathlean (2008), who reported that while a number of students in their study had positive placements, too many had experiences where their learning was not optimised and their competence and confidence were negatively affected. Like the students in this study, Levett-Jones et al. (2009) found that some mentors seemed to disregard students’ feelings and made little attempt to hide their impatience and frustration” (p371).

 

 

Maura Buchanan also focuses attention on the clinical environment:

“ I would argue that the main responsibility for failing standards lies not with nurse education, rather, with the clinical practice environment for which employers must take blame” (p17).

 

Jenny Aston also points to deficiencies in the clinical environment:

 

“With university based training (sic), considerable responsibility is left with the placement mentor to ensure that students have the necessary hands-on nursing skills. Many students have minimal one-to-one learning from their clinical mentors,who are busy with their own responsibilities, and have little or no protected time to teach the essential skills…University lecturers rarely have the time to visit, let alone work, in the clinical areas”. (p21)

 

The responsibility for safe compassionate care rests with Trust boards. NHS management has taken its collective eye off the ball and is often ill equipped to know if poor care is being given. Universities cannot do the work for Trust boards. Any call for a return to apprenticeship training within NHS trusts must address this fundamental issue. In far too many cases there are insufficient governance practices in place to ensure care standards are upheld. Aston argued:

 

“There is a need for governance measures to be in place to ensure that care is of a high standard as there will always be a conflict between cost and quality. Board level

decisions need to be based on a good understanding of how care can best be delivered and measured so on the ground clinicians need to be informing high level decision makers. Great care needs to be taken to measure the right things and not just numbers; otherwise real improvements will not be demonstrated. An experienced pair of nursing eyes and ears can identify good and bad care in a way that complex audits or form filling may fail to achieve”.

 

Roy Lilley has often stated: ‘Fund the front line. Make it fun to work there, that way you will make Francis history”. Nurses and nursing students have been criticised as lacking in compassion. No doubt this is true for some nurses. However, it is the lack of governance and poor clinical environments that both grows uncaring attitudes and fails to weed them out. Trust Boards through excellent management must implement strategies that ensure the front line is properly supported and developed.

 

When only 1 nurse provides poor care, that is their personal trouble….when we have had a catalogue of reports into poor care,  that is a public issue and we should not find the solution in the situation of any one nurse. We must look into the economic and political nature of NHS Trusts and of society to move beyond criticisms of individual nurses and their personal failings.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

Beer, G. ed. (2013) Too posh to Wash. 2020.org  Too Posh to Wash?

 

Bradbury Jones, C., Sambrook, S., and Irvine, F. (2011) Empowerment and being valued: A phenomenological study of nursing student’s experiences of clinical practice. Nurse Education Today. 31 p368-372

 

Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. doi: 10.1111/1467-9566.12017  pp1-17

 

Levett-Jones, T., Lathlean, J. (2008) Belongingness: a prerequisite for nursing students’ clinical learning Nurse Education in Practice, 8 pp. 103–111

 

Levett-Jones, t., Lathlean, J., Higgins, I., and McMillan, M. (2009)

Staff-student relationships and their impact on nursing students’ belongingness and learning Journal of Advanced Nursing, 65 (2) pp. 316–324

 

Lindop, E, (1999) A comparative study of stress between pre- and post-Project 2000 students Journal of Advanced Nursing, 29 (4), pp. 967–973

 

Menzies Lyth, I. (1960) The functioning of social systems as a defence against anxiety. Human Relations. 13 (2) 95-121

 

Melia, K. (1987) Working and Learning: The Occupational Socialisation of student nurses. Tavistock press. London.

 

Solvoli, B., and Heggen, K. (2010) Teaching and Learning Care – exploring nursing students’ clinical practice. Nurse education Today. 30 (1) p73-77

 

Willis Commission (2012) Quality with compassion: the future of nursing education. http://www.williscommission.org.uk/

 

Wright Mills, C. (1959) The Sociological Imagination. Oxford University Press. Oxford.

 

An unachievable utopia in nursing practice? Utopia will not be paid for by the ‘Greedy Bastards’

The Politics of Nursing: Care is expensive: get used to it.  

Introduction

By now many nurses will be feeling a mixture of despair and insult they have received following the many reports into poor quality care. These feelings can lead to disenchantment, disengagement and disillusionment with both politics and health care delivery. Jane Salvage (1985) suggested that nurses ‘wake up and get out from under’ and while recognising that for some this past entreaty to engage politically may further entrench those feelings, the need for nurses and nursing to do so has not diminished. As Stuckler and Basu (2010) argue, government policy becomes a matter of life and death as ‘Austerity is killing people’. Nurses are part of the front line in promoting health and caring for those who are ill or living with chronic conditions. Their work is therefore framed by politics and political decisions. The bottom line is that there is a ‘bottom line’ to care, societies prioritise resources depending on their values, however there is not a level playing field in this regard. Care is under resourced, undervalued and often invisible. As millions of people in the UK, and billions across the globe, experience a daily struggle to both give and receive care Nursing must ally itself with the progressive forces which seek to redress the balance forces of power which currently results in gross inequalities in health and poorly funded care provision. In this article I wish to remove the ‘flowers from the chains’ so that we more clearly see what holds us back from progress in care giving.

The Politics of care

This summary of a recent article by Curtis (2013) is worth reading as it sets up what some are experiencing as they struggle to reconcile care and the cultures that surround it:

“Nursing faculty are facing challenges in facilitating student learning of complex concepts such as compassionate practice. There is currently an international concern that student nurses are not being adequately prepared for compassion to flourish and for compassionate practice to be sustained upon professional qualification…..nurse teachers recognise the importance of the professional ideal of compassionate practice alongside specific challenges this expectation presents. They have concerns about how the economically constrained and target driven (my emphasis) practice reality faced by RNs promotes compassionate practice, and that students are left feeling vulnerable to dissonance between learned professional ideals and the RNs’ practice reality they witness”.

A key point made in the article is that of the requirement for strong nurse leadership in clinical practice to deal with those factors that make care and compassion difficult to practice fully. That being said, no amount of good leadership will address the basic problem of the cost of caring: ‘who pays?’ Poor quality care is the fault of the person giving it, personal accountability for neglect and abuse cannot be sidestepped. However, we need to bring our sociological imaginations to bear so that we can more fully understand the antecedents to abusive institutional care. These include poorly funded care provision for a low status Cinderella service.

Too much of the discussion of the failings in care do not take into account the political economy of care in societies and the historical antecedents that have brought us to where we are. Instead, we get discussions around changing ‘cultures’. Reconciling professional ideals to actual practice is very difficult given the organisational cultures many nurses work in, and the almost grudging support given to nurses by the political system set up by what Graham Scambler (2012) calls the Corporate Class Executive (CCE) and the Political Power Elite (PPE). The bottom line, and that is a phrase the CCE recognise, is that care costs money. One of the critiques of the Mid Staffs tragedy was that corporate self-interest was put ahead of patients’ safety (Francis (2013).

There have been many reports regarding the health and social care of elderly people and it seems to be that their needs are outstripping both private and public provision for them. J K Galbraith coined the phrase ‘private affluence-public squalor’ to describe the mismatch between what is resourced in the private sector and the public:

There’s no question that in my lifetime, the contrast between what I called private affluence and public squalor has become very much greater. What do we worry about? We worry about our schools. We worry about our public recreational facilities. We worry about our law enforcement and our public housing. All of the things that bear upon our standard of living are in the public sector. We don’t worry about the supply of automobiles. We don’t even worry about the supply of foods. Things that come from the private sector are in abundant supply; things that depend on the public sector are widely a problem. We’re a world, as I said in The Affluent Society, of filthy streets and clean houses, poor schools and expensive television. I consider that contrast to be one of my most successful arguments”. (interviewed in 2000).

Galbraith first wrote about this process in 1958.

As governments embrace austerity policies, this tendency for capitalism to funnel resources, research and development into goods and services that make a return while ignoring public provision for those things that do not have immediate impacts on improving shareholder value or the price of stocks, increases. Care is seen as a cost and not a benefit to those who decide where the investments should be made. Private care companies will provide care with an eye to the balance sheet. This results in hiring under educated and poorly trained staff who too often lack supervision and development in high patient to staff ratios (Salvage 2012). The NHS is no different, but is also now handicapped by various factors making its provision seemingly expensive for society. While the current (2013) Chancellor states that NHS spending will be ringfenced, the true position is that care straddles both health and social care sector provision and is thus characterised by means testing.  It is accepted fact that our population is ageing with forecast increases in dementia and diabetes, health and social care services will experience increased pressures as demands and frailties rise. The argument is about who is going to pay for the provision of care?

Frail elderly people need a lot of care and that care is expensive. Let us not forget our history – why the NHS was set up (Abel Smith 2007), who struggled to get it in into place and why, and the functions women especially played in the private sphere (Elshtain 1981) of care both for children and the elderly. Modern Industrial society was both capitalist and patriarchal with care firmly in the private domain. No state funding as we would recognise it was provided because this was expensive. Patriarchal attitudes would not define it as ‘proper’ work and so could be left to women. The Parish, Poor laws and workhouses were the backstop for those unable to fend for themselves, for those without the family, and that often meant women, looking after them. The working class had to struggle to get health and education properly funded. Enlightened Victorian philanthropists and entrepreneurs realised that if they wanted workers to keep working then recreation and education had to be provided. This provision was despite the capitalist dynamic for profit, not because of it.

We have come a long way as social democratic pressures finally provided the NHS and Education, as the elites also were won over to the need to provide care. The ‘One nation’ Tories at least understood that a prosperous society had to take care of all of its members, of course there was some self interest in this – we needed soldiers who were fit for the battlefield, and we needed healthy workers for the factories. This is a simplistic history as it is more nuanced than this. However, over the last 30 years or so we have seen reversal of this enlightened social democratic outlook on care and public health and care. The need for care is increasing but this is occurring just when the elites are pulling back from their responsibilities. They look at what state provision will cost for high quality elder care and are frightened.  They also have a visceral loathing of state provision…because it costs them money through taxes they do not want to pay. They say it is because the state is inefficient and anti-democratic, that state provision is the road to serfdom. Suffice to say that the current involvement of the CCE with the PPE is extremely antidemocratic but their right wing press cheerleaders have not spotted it or prefer to ignore it.   Seamus Milne  has eloquently exposed how corporate power is corrupting politics.

The neoliberal capitalist agenda (Crouch 2011) requires the state to pull back from earlier involvement on education and health. The CCE and the current PPE have swallowed an ideology that simply accepts private provision = good, public provision = bad. This is why we are seeing the conditions of an affluent society being characterised by a hugely increasing wealth gap. This agenda also allies itself with patriarchal views on the proper role for women – get back in the kitchen girls and look after the kids…and now, of course, Gran as well.

Austerity is now the smokescreen for dismantling of the state provision for care. Does this mean that lack of compassion is directly related to neoliberal policies?  To accept that is to think in an overly simplistic cause effect relationship. Societies are more complex than that.  Of course poor quality care pre dates capitalism and the NHS, however capitalism (and its often hidden twin patriarchy) sets the agenda and the organisational forms and institutional arrangements in which care takes place. This now means as budgets get cut and savings asked for, nurses will be asked to provide more for less. This has been always the case; nursing work as womens’ work (Hagell 1989) has largely been invisible emotional labour (Smith) which has been poorly paid and supported, instead their rewards have been patronising labels such as ‘Angels’. Nurses know what they need to provide care and they can do it if given supportive organisational cultures and the power to actually direct, organise and manage care properly.

As Roy Lilley argued on nhs.managers.net:

(The Francis report 2013) talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will.  Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have stood still.

and…

“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”

And there you have it. Do the austerity addicts think it is the proper role of the state to fund the front line. No, they hanker after a US style private provision with the family, the big society volunteers and women to take up the slack. That will not wash in a hospital ward or a care home full with frail elderly patients.

Nurse educators and their students do not work in a socio-political vacuum. However, one would think that they do if the content of curricula and the learning experiences planned are anything to go by. Indeed any discussion around political economy, patriarchy and capitalism is liable to be met with surprise, apathy, disdain apart from those engaged in teaching the social sciences in nursing. I would argue that nursing cannot shy away from addressing these questions. Nurses as women, who experience the requirements to care in both their domestic and public lives, bear the brunt of the demands of a society which needs that care to be done but is unwilling to fully fund it. It might be fair to suggest that since about the 1980’s both feminism and social democratic politics took their eyes off the ball or felt that because progress had been made the struggle was nearly over.  It is not. We need to argue for the social value of care and against privatised individualised provision which falls unfairly on the shoulders of those who often do not have the resources to provide it.

Caring is not sexy – it is not fancy infrastructure projects, it does not make millions at the click of a mouse;  hedge funds and private equity firms don’t crack champagne bottles over the needs of the frail elderly. Care is unglamorous emotional labour, involves often dirty body work, offering little in the way of recognition and prizes – there are no Golden Globes, Oscars or Baftas. There is no end point, no project that is completed and shown off, no bonuses to be earned. ‘Top’ Universities show off their ‘top’ professions: law, medicine, business and science whose courses are oversubscribed due to professional closure and the high salaries they attract. The children of the elite are groomed and public schooled to ensure they attend the ‘right University’ and study the ‘right’ subject while eschewing nursing, which struggles to gain academic credibility and value among society and Russell group elites, while its core concept is seen to require no education at all.

Nurses are in a political struggle whether they realise it or not. For the sake of all us who will require care, don’t let the greedy bastards grind us down

 

 

 

 

 

References:

Abel Smith, B. (1992) The Beveridge Report: its origins and outcomes. International Social Security Review 45 (1-2) pp5-16

Curtis, K. (2013) 21st Century challenges faced by nursing faculty in educating for compassionate practice: Embodied interpretation of phenomenological data.   Nurse Education Today, http://www.nurseeducationtoday.com/article/S0260-6917%2813%2900170-6/abstract

Elshtain, J. (1981) Public Man, Private Woman: Women in Social and Political Thought. Princeton, NJ: Princeton University Press

Scambler, G. (2012) Elements towards a Sociology of the Present. December 6th http://grahamscambler.wordpress.com/2012/12/06/elements-towards-a-sociology-of-the-present/

Care, Compassion and the Social Structures of Oppression

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.

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