Whilst The Guardian highlights the negative impact of ‘time-poor’ nursing practices on patient care it needs to be emphasised organisational structures that support a mechanistic approach also need to be addressed.
As the BMJ publishes a report which suggests nurses are being forced to “ration care” I am beginning to wonder if this government is incapable of learning from past mistakes. Since being in power we have had pronouncement after pronouncement on the need for ‘compassionate care’ leading to the vilification of many who try to provide such care, but who are impeded by organisational structures and ‘management’ strategies more suited to a car plant than a hospital ward trying to care for individuals when they are ill. Nursing staff do not generally enter the profession to provide poor quality care, on the contrary the majority want to provide the best care possible, however, once in the system the working practices in many hospitals seem designed to stop this occurring. Research suggests staff develop ‘social defences’ to cope with the disparity they experience.
Jaques (1955) initially used the concept of social defences ‘‘to refer to unconscious collusion or agreements within organisations to distort or deny those aspects of experience that give rise to unwanted emotions’’. The concept was developed later to take into account structural factors ‘‘arguing that social defences were the result of poor organisational structures. This provides a useful concept to begin to understand how structural systems interweave to produce an environment where poor quality care might flourish in a bid to meet the needs of the organisation and make care systems affordable.
Research suggests Nurses use social defences to cope with high levels of stress and anxiety associated with the job. Defence mechanisms include care for patients split into individual tasks undertaken by a number of nurses, one nurse performs the same task to many patients rather than working with one patient to provide all their care. This facilitates a distancing between the patient and nurse, which protects the nurse emotionally. Organisational factors support a depersonalised approach by moving nurses around wards, which then allows the nurse to distance themselves from patients so as not to become emotionally involved. Other social defences include a denial of feelings and over emphasis on professional detachment and strategies to reduce anxiety around decision-making, for example working in prescriptive ways, performing prescriptive tasks, and delegating decision-making. This may be reminiscent of current care provision within hospital and residential settings, where the lack of connection between patient and carer arguably facilitates an environment in which poor quality care becomes the ‘norm’.
Research by Calnan et al. (2012, p. 1) on the provision of dignified care for older people in acute hospitals highlights this point when they ‘‘found a lack of consistency in the provision of dignified care which appears to be explained by the dominance of priorities of the system and organisation.
Structures that depersonalise the caring relationship will not lead to the delivery of compassionate care. Compassionate care is more than a mechanistic task, it is emotionally and psychologically draining, staff need support not an organisational structure that is unsupportive. This government has to stop pointing the finger at the previous administration and learn from their mistakes.
I am reminded of the ‘Peter Principle’ which asks “Why does history keep repeating itself? Because nobody ever listens”. Quite.
(If you would like to read more on ‘Social Defences’ you can access a journal article I have written on the subject published in the Journal of Adult Protection)