Hungry, thirsty, unwashed: NHS treatment of the elderly condemned – The Independent 19 February 2011

Are nurses on geriatric wards callous, thoughtless and ageist, or poorly led and themselves victims of a sick culture?

The culture of an institution has a direct and powerful influence on the way staff in it behave towards others, in particular those who are vulnerable because they are necessarily dependent or carriers of stigma.  In very hierachical organisations, for example, staff are more likely to have hierarchical relationships with patients since what is done to them they will unconsciously do to those in a subordinate position. 

Occasionally, there will be bloody-minded or charismatic individuals who are naturally resistant to this dynamic but, in an unhealthy organisation, they themselves will be vulnerable to ploys to ensure they are marginal or discredited.   Such an organisation will prize obedience and conformity, and be covertly hostile to spontaneity and intuitive displays of humanity because they threaten to breach the circle of control.  It will treat staff as conduits for a centrally determined project, as functionaries rather than agents. It will underpin this approach by rewarding careerism at the expense of vocation.  That is, it will confer status and prestige on those who are willing to compete for them and disparage those who instead compete with themselves to be better or more skilled at their work.

One insidious consequence of this culture is that fear becomes the spur which drives the behaviour of staff rather than a wish to learn, develop, mature or excel.   They quickly begin to see their primary task as that of following procedure and providing data required by the organisation in order to avoid censure or punishment.  A by-product of this is the erosion of confidence and, in particular, the so-called use of self; that is, using one’s skills, experience and humanity in the interests of patients.  The organisation will reinforce this by conveying, both explicitly and covertly, to staff that they can only improve through training, appraisal, performance management and other concrete approaches to a cultural-psychological matter. 

Other phenomena serve to perpetuate the status quo. Most important, perhaps, is the failure to understand what the psychoanalyst, Otto Fenichel, called the “objective task”.  He believed that this led inevitably to “inefficiency and disappointment”.   A very clear example of this can be seen in the care of people with mental health problems who pose a serious risk to others.  Almost all staff tend to see their task as preventing patients committing very serious offences, in particular, homicide.   When some patients do commit such an offence, as will inevitably happen from time to time, staff will almost universally see this as evidence of a major clinical failure on their part.  But, more important, their mistaken reading of their task leads to competing and contradictory feelings, involving fantasies of omnipotence on the one hand – I can and must prevent patients harming others – and debilitating anxiety on the other – any patient could harm anyone at any time.  This muddle impairs their ability to contemplate, let alone carry out, what should be their primary task; which is to gather all the information about risk which is available, making sure it is full and accurate, and to make defensible judgements based on it about what interventions should be made.

In healthcare generally, task is confused with outcome, as a result of which the focus is on the latter to the exclusion of the former. Adaptive, humane and effective institutions which provide such care will only develop when there is continuing, consensual discussion about and identification of the primary task.  This is very much a matter for institutional introspection rather than material for an outward-looking mission statement.   The simpler the task is the better, because it will require much more thought – and continuing thought – than a very detailed list of sub-tasks.  For example, a helpful and productive way of seeing the task for all staff working in the field of physical or mental health is that it is, first, to treat the organisation, then to treat oneself, and finally to treat the patient.  In other words, it would be the duty of staff at every level to make sure that the organisation is psychologically and culturally healthy; then to make sure that they themselves are healthy (in their attitudes, working practice, relationships with colleagues and patients, management of stress, and so on); and finally to maximise the health of patients.

This kind of task is much more demanding than simply working through a list of things that must be done to or, preferably, with patients because it requires continuous self-audit at all levels in an organisation.   And this much we can extrapolate from our own experience or knowledge of families, where staff feel neglected, unsupported and even persecuted by an uninterested parent institution or by their leaders, the care which they in turn provide to those who are dependent on them is likely to be tainted by similar feelings.