Tag: Poor Nursing care

The personal is political; care in an age of spectacle.

Are we really surprised that the BBC’s  Panorama has again uncovered  poor quality care and abuse in a home for older people?

We know the roots of this, and I have previously argued that this is a political game. This is also personal because, and this point has been made many times  before, I will be old one day and may well require care. Therefore I do not want to be treated like sh*t as a resident on the Panorama  film stated. It happens because the care sector is undervalued, invisible, ‘women’s work’ and it is thought by some  that it can be done by those with little training, poor supervision, risible pay, poor patient ratios, no professional development and inadequate management.

Individuals will of course be blamed and sacked citing ‘accountability’ as if it is the holy grail of quality care and patient safety.

What to do? The first is to recognise that this personal trouble is a political issue and nurses are front line staff in the trenches. In the UK for far too long nurses have been reluctant to use union power to address these fundamental issues. Yet, just when we need it, union membership across all employment sectors have dropped as workforces became more docile in the face of deregulated labour markets. Faced with the ‘flexibility’ requirements demanded by employers, resulting in the growth of zero hours contracts, part time working, minimum wages as targets rather than base lines, workers have become more pliable generally. Nursing, being a gendered occupation with its emphasis on self sacrifice and care, has historically shied away from exercising any worker power while simultaneously picking up the crumbs from the medics table (doing their ‘skilled’ tasks for nowhere near the pay) and now bowing to the control of their work as dictated by management.

In California, in the US, nurses are joining Unions and have a staffing ratio law of 5:1 for med/surg, 2:1 for ICU, and Psych 6:1 meaning five patients with 1 nurse. CA AB394 came about by the CA Nurses Association to implement their RN Staffing Ratio Law. William Whetstone (Professor of Nursing California State University)  states “Staff nurses were sick and tired of being abused, putting up with crappy workloads, incompetent nurse administrators and managers, and on and on. I can remember when I did staff nursing dealing with a patient load of 10 to 12 patients with no thought to their acuity. As a result, CA became the first state through the effort of the CA Nurses Association to establish RN-to-patient ratios. The law was successfully implemented January 1, 2004”.

Is this an increasing phenomenon? Are we finally seeing a backlash against the dominant political hegemony that does not want to pay for care? We can study this until forever, but that fact remains – care costs. It costs a lot, requires skill and adequate ratios.

In California it seems nurses have had enough, got organised and agitated for change. They have looked beyond the representations of nurses as caring angels and seen themselves as the exploited.  They have plucked the imaginary flowers from their chains and acted.

Consumer capitalism would not want this happen because care is seen, in this context, as a cost to be born not by society but by individuals and families. Consumer capitalism instead wants to fill our heads with distractions and representations using the ‘spectacle’.

News and other media constantly feed us representations of the world that actually do not exist; they are constructed for news and or as entertainment. Panorama falls into that trap because it represents poor care in a particular way and is unable to drill down to the root causes. The TV itself is a medium of the representation of actuality and can lull us in to classifying the poor care we see as almost entertainment; the lines between truth and  fantasy become blurred.

 

“In societies where modern conditions of production prevail, life is presented as an immense accumulation of spectacles. Everything that was directly lived has receded into a representation” (Debord 1967).

Consumer capitalism has ripped the citizen role from the heart of nursing and replaced it with consumerism in which we are presented daily with ‘the spectacle’ – representations of reality that are without form or substance but which service to make sacred the profane. The spectacle specifically aimed at women include the array of women’s magazines which preach that you can never too thin or that your breasts require surgical enhancement; thus are we distracted about what is truly real by a false representation, within care employment contexts that are precarious, undervalued and invisible. Feminists know this, critical theorists know this, those with a sociological imagination know this, many women actually feel the cognitive dissonace that this engenders. In California,  nurses have acted as citizens, able to see pass the distractions for long enough to see exploitation as it really is. In the UK those nurses who can see the reality, need to the support to take charge of care in this country.

Ordinary citizens need to organise their frustrations and anger over health and social care and cohere into a viable opposition. Unfortunately UKIP are currently presenting another false representation with the spectacle of Nigel Farage presented as an ‘ordinary bloke’ that nearly 30% of the electorate are falling for.

We saw a spectacle of poor care again last night, lets not allow it to become entertainment for its shock value, lets instead urge action by all of us to provide the care older people deserve.

 

Government, managerialism, leadership and poor care in the NHS

Today the government responds to the Francis Reports into the care failings between 2005-2009 at Mid Staffordshire NHS Trust. What can we expect?

 

I suspect that there will be a good deal of initiatives and new regulatory effort but little in the way of actual practical relevance.

 

In March 2013 the government published its initial response Patients First and Foremost in which David Cameron apologised to the families involved through parliament acknowledging systemic failures. It is to these systemic failures we must look to find some answers, but I suspect that my definition of a systemic failure may not be the same as Cameron’s. First lets consider where we are so far.

 

Jeremy Hunt’s foreword in March focused on creating a culture of safety, compassion and learning that is based on cooperation and openness. He identified four key groups who are essential in providing this culture:

 

  • Patients, service users, families and friends.
  • Frontline staff.
  • Leadership teams – Trust boards.
  • External structures: commissioners, regulators, professional bodies, local scrutiny bodies and Government.

 

The government’s response was, through the CQC, to appoint a new chief Inspector of Hospitals. Secondly, making hospital performance more transparent through a system of ratings. Then, something called a ‘single failure regime’. There would also be a Chief Inspector of Social Care. In addition the government would ‘foster a climate of openness’. How it would do that when it has no control at all over NHS organisations seems moot.

 

That was 8 months ago and so we cannot expect too much to change in a group of organisations that make up the NHS brand, a brand that is now a complex system of public and private provision distinct in organisational form from each other and from social care provision. What remains of the complex system is the underpinning Health and Social Care Act 2012.

 

Many of the 12 points in this March response are hard to critique, for example who does not want ‘Respect and Dignity?’ However there is a little nugget, point 8:

 

“We will work together to minimise bureaucracy, enabling time to care and time to lead, freeing up the expertise of NHS staff and the values and professionalism that called them to serve”.

 

This goes to the heart of the process of care, but there are no short cuts to doing this. Minimising bureaucracy requires leadership to address certain managerialist cultures. Prior to Mid Staffs, Leadership was seen as a key aspect of NHS culture changes. However, Leadership operates in certain organisational cultures and that rests mainly with management and can be strangled by a managerialist culture putting organisations into a catch 22: we need leadership to change cultures but we need culture change to allow leadership. However, it is bureaucratic management chasing non care oriented targets in order to maintain or gain Foundation Trust status which have distorted the care process and hampered frontline staff’s ability to deliver. This operates in wider socio-political context of the devaluing of care in that we accept the need for care but will not provide financial and social structures to allow it to flourish. Instead we have individualised care, leaving it mainly to families and women who are often provide it for free or for low pay.

 

Of the four groups identified above by Hunt, it is the leadership teams, especially hospital management and their Boards, which carry the most responsibility for care in NHS Trusts. Patients can exercise their voices, frontline staff can advocate or try to exercise clinical leadership, external groups can respond to failures often only after the event and were largely ineffectual as they may continue to be. Roy Lilley suggested that weighing a pig does not make it fatter – you have to build in quality from the outset, inspection is a post hoc activity. Trust Boards however set the tone and provide the resources and thus have the primary responsibility for the provision of good quality hospital care.  The Secretary of State for health has now abdicated that responsibility in an increasingly market driven health care system.

 

John Robinson, age 20, died in 2006 as a result of a ruptured spleen after a mountain bike accident. He was discharged from Mid Staffs Accident and Emergency department and died less than 24 hour later. A second inquest is being conducted. Caution must therefore be exercised in making any conclusions about the quality of care John received and whether it was in fact deficient. Claims regarding negligent care require certain conditions to be met and this has not been established in this case.

 

John’s parents claim that he was examined by a junior doctor, and that a consultant was not available. They suggested that if a more senior doctor had examined John then the chance of a ruptured spleen might have been considered. The junior doctor may have been incompetent, or she/he may have been acting within the limits of his competence, we do not know. The point however is that staffing of accident and emergency, and the training and development of staff who could spot this condition, are ultimately the responsibility of the Trust Board. Professional staff have a duty to make known their concerns regarding staffing and the competence of the team they work with, but they need the confidence to act on their concerns and the recognition by management that the exercise of clinical leadership involves challenging structures of support for clinical practice.

 

Therefore, professional staff have to be able to exercise clinical leadership safe in the knowledge that issues will be listened to and acted upon. However, managerial leadership may militate against this because their aims and objectives may blind them to real clinical needs. This was a criticism of Mid Staffs management.  In John’s case, if it was the poor decision making of an inexperienced junior doctor that was a major contributor to his death, we do not know if clinical leadership was exercised to address any issues of the training and support for junior doctors.

 

John Edmonstone (2008) suggested that clinical leadership is distinct from managerial leadership and is often ignored or not addressed by those considering leadership in the NHS. In addition he describes a disconnected hierarchy operating in health care organisations: a clinical hierarchy and a managerial hierarchy. This disconnect results in differing objectives, visions and ways of working. This is reflected by Robert Francis (2013 p3) who argued that the failings at Mid Staffs was primarily caused by:

 

“a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care”.

 

Prior to this Hewison and Griffith, in 2004 argued, “too much emphasis on leadership without an equal concern for transforming the organisations (nurses) work in may result in leadership being added to the list of transient management fads”. Hewison in 2011 went on to argue that the focus on leadership as a solution to organisational ills remains in the NHS. This is rooted in assumptions that leadership, changing cultures and producing effective leaders will result in improvements in management and organisations. Hutchinson and Jackson suggested in 2012 that discussions around leadership often fail to address the issues of power, politics, dominance and resistance in organisational cultures. Both pre date Francis comments about the nature of Trust management at Mid Staffs.

 

Faugier and Woolnough (2003) provided some evidence of what organisations feel like to work in. and thus illustrate how management cultures can distort care practices. They describes three types of organisation:

 

  1. The Machine
  2. The Choir
  3. The Living organisation.

 

In their research 45% of respondents stated that their organisation felt like a machine in which leadership is generally driven by senior management to establish order and control. Strategic decisions are made through a formal planning process and change is planned and programmatic. Employees feel like a ‘cog in a wheel’. Faugier and Woolnough concluded that there was serious work to do to ensure clinical staff feel engaged and empowered. They argued that too many staff felt like cogs with high levels of disengagement and disillusionment and that that the implications for patient care were obvious. This was written in 2003, before Mid Staffs made the headlines. One can’t help but think that the antecedents for poor quality care were already established and were being written about for some time.

 

Questions remain: Will the government be able to do anything about how individual Trusts are run and financed? Will the frontline be properly staffed and supported; will they feel free to express concern about poor quality care?

 

Is clinical leadership any better supported, and will staff feel empowered and engaged? Will today’s government response address any of the fundamental issues?

 

 

Issues to address to address in this regard:

 

  • In a public sector organisation, clinical leaders cannot easily affect, or redefine public policy or legislation set by politicians and so they operate within the conditions set by others. Since the Health and Social Care Act Government has released the reins of control and conditions to NHS organisations and can no longer provide or dictate such issues as minimum staffing levels without enacting new legislation.

 

  • Nursing culture may inhibit clinical leadership development; issues of gender and medical power may continue to inhibit strong nursing leadership within Trusts and in clinical commissioning groups.  Has nursing got the respect of the public, politicians, policy makers and other professional groups to allow the to exercise strong leadership?

 

  • The focus on developing the person, their competencies and their traits, which are often based on male assumptions about what leadership looks like, may be in conflict with the exercise of leadership that focuses on relationships (shared leadership) within complex organisations.

 

  • The ratio of professional nursing staff to non-professional staff requiring training, supervision and regulation by clinical leaders is wrong. Not enough nurses, too many support staff.

 

  • Health care organisations may be risk averse and heavily regulated which counters leadership development that encourages risk and creativity and the challenging of the status quo.

 

  • Inspection and regulation are post hoc activities: are the CQC, Monitor and the Professional Bodies fit for purpose in terms of preventing poor quality care?

Care quality in the NHS

.”‘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. The very structure of opportunities has collapsed. 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’. (p9). (C Wright Mills – The Sociological Imagination).

….today we hear about the safeguarding tragedy that was Daniel Pelka. Again, communication issues between agencies and the failure to act have been highlighted. His parents are in jail. If only one social worker failed then we should look to the character of that social worker. When we have a historical record of failures which all highlight communication issues and failures to act, we will not find solutions only in the failings of individuals, the socio-cultural systems itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society.

….we have heard about the care failings that was Mid Staffs. Again, neglect and abuse of frail elderly patients were highlighted. If only one healthcare professional or manager failed, then we should look to the character of that professional. When we have a historical record of failures which all highlight neglect and abuse, we will not find solutions only in the failings of individuals, the socio-cultural system itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society and not just the striking off professionals from registers.

Sir Brian Jarman stated in a recent Lancet article:

“To improve the quality of care in UK hospitals, I would reintroduce the Independent Review Panels and Community Health Councils and develop monthly complaints alerts similar to the mortality alerts. Regulation would be more independent if the CQC reported in public to Parliament, and there would be better communication if it were integrated with Monitor. Additionally, it is important to ensure  there are minimum staff-to-patient levels of doctors and nurses, with 65% trained nurses and  regulation of health-care assistants (my emphasis). I would aim for

total physicians per head of population at the EU average. Ideally I would also like to see training  introduced for the boards of trusts and for them to
have equal representation of patients, clinicians,  finance, and managers. There has been a decade  of concerns about the quality of care in our
hospitals: patients have been ignored, the  regulatory systems have failed, and there has been a culture of denial”.Instead we get the mess that is the Health and Social Act which is supposedly a ‘reform‘, and the NMC engaging in ‘re-validation’.

When will we learn that inspection and revalidation are external post hoc care quality issues, there is of course a place for these processes but there is a need to ensure the quality of care is structurally built into care delivery systems – and that means ensuring that you have enough staff, enough of the right sort of staff, educate and support them and engage in continuing professional development, appraisal and performance management if necessary.

“Missed care” in Hospital, we may need more nurses*

Yesterday this research based report argued “There is strong evidence to show that lower nurse staffing levels in hospitals are associated with worse patient outcomes. One hypothesised mechanism is the omission of necessary nursing care caused by time pressure—‘missed care’ “. To investigate this a survey was undertakenof 2917 registered nurses in 401 general medical/surgical wards in 46 general acute National Health Service hospitals in England. This is a decent enough sample frame to begin to make inferences, so what did the researchers conclude? That, according to this cohort care is frequently left undone and that this, unsurprisingly, is related to lack of time. The activities include: comforting or talking with patients, educating patients and developing/updating nursing care plans. Two factors also highlighted was that 1) the number of patients per nurse  and 2) ward patient safety ratings are significantly associated with missed care. This report follows a warning by nurse leaders over nursing numbers and a call for minimum staffing levels.

The wider context is of course the concern around the quality of nursing and medical care given in some Trusts, some of which have focused on ‘compassion in care’. However, following the publication of the Francis Report, the health secretary,  Jeremey Hunt, failed to argue for minumum staffing levels. That being said NICE is working on a tool to be used to establish just such levels. It has been reported that Hunt confirmed that it is not the job of the health secretary to do so.

 

It is very hard to see that when the NHS is experiencing the Nicholson challenge and may well have to deliver further costs savings  that Trusts, will spend any more on staff.  Considering ward budgets,  pay for staff can be the single biggest expenditure.  The context is that, as I heard clearly stated in a Trust recently, that “this is not a hospital, this is a business” and that budgetry control involves making financial savings year on year. Bruce Keogh, in his recent 2013, report argued that three dimensions of quality were: clinical effectiveness, patient safetey and the patient experience. These three in reality have to be delivered withing a context of cost savings.

This is market discipline in the health service. Private sector organisations (whether they for example, like Farmers, receive state subsidies or not) know this discipline very well. Control your costs or you competitiors will undercut you and force you out of business. However, even in the private sector cost is not the only concern – quality is and customers make decisions not only on cost but the quality of the service or product.

People know however that the NHS is not a private sector organisation and that switching brands is not an easy way to signal dissatisfaction. People also know that poor staffing levels seriously diminishes the quality of the service they recieve. there is no geting away from the fact that care costs money.

This is therefore political and a social battle. The NHS is currently compared to other healthcare systems very good value for money. However, chroinc staff shortages will challenge public support and may make some consider private provision. This is the wrong solution to the wrong problem.

 

 

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/

The Francis Report and poor quality care

Roy Lilley has argued:

Francis 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 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.”

A nurse was quoted on… wait for it….the ‘One Show’ saying that she came in on her day off to feed a patient, another story was that two male nurses laughed at a half naked elderly man with a catheter. Two ends of the same care story that is the NHS. There is a problem with attitude/culture but there is a problem with structure (e.g. poor staffing) which gives rise to poor culture. Cultures arise out of structures, they do not just appear out of nothing. The way people relate to each is influenced by so many variables but in an organisation set up with a purpose in mind, those variables start to filter down into the structures that are in place to fulfill the stated purpose. If the purpose is to diagnose and treat a minor illness in an otherwise healthy person, the structures you need are relatively straight forward. The structure of staffing: A doctor or suitable qualified nurse with enough time to take a history, carry out an examination, come up with a diagnosis and then initiate treatment. The structure of place: A clean, well lit, warm private space. The structure of resources: for example assessment tools, stethoscopes, sphygmomanometer, examination table….  These are the foundations to encourage a culture of respect and co-operation. Of course having the structure in place does not guarantee a patient centered culture. The reverse is true, take away the GPs structures and you will more than likely get a little less respect and quality care.

The emphasis on culture and NHS leadership has let society off the hook because we then don’t talk about structures. No doubt the culture and leadership in some Hospitals must change…in addition society has to accept that care work costs money. We just don’t seem willing to put in the extra resources to ensure that the vulnerable are not abused. Feminists have long argued that because patriarchal societies view ‘care work = women’s work’ and women’s work has been seen as ‘domestic’ and unskilled (i.e. required very little training because it is ‘natural’ to women) , care work receives little recogniton and value and sinks into invisibility. The structures to support care work in the UK and in many ‘advanced societies’ are creaking to breaking point, relying on armies of unpaid and unsupported family members.

The analogy is with motherhood and the structures that support it: unpaid, hard work, no training, no sick pay, little support…many mothers go the extra mile every single day, some crack under the strain and abuse or neglect. A minority of mothers abuse because they know no better, they are ill or have given up caring. Any care work that is not properly valued recognised and supported runs the risk of increasing the ratio of abuser to saints. Just as mothers need all the support they can get from society, so do nurses. If you isolate, divide, and undervalue their work do not be surprised when there is an increase in neglect. Society ascribes value to work through pay, status and perks….and so you can get an idea of what society values by examining who gets the pay, status and perks. Capitalism has long divided ‘proper’ work (men’s work) in the public sphere which it has paid for on the one hand, and ‘non’ work (female work) in the private sphere, i.e. the home, which it is unwilling to pay for, on the other. Socialists and feminists arguments have tried to get this private sphere work as being properly recognised in the patriarchal hiearchy and so we have child benefit etc. Historically, if men were nurses, and care work the preserve of men, this would have elevated its status and hence support, education and pay. Roy Lilley is calling for funding the front line, to support the structures of care. Watch however how we turn ourselves inside out trying to correct cultures.

 

 

 

 

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

 

 

 

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