A shameful state of care?

The gravity of the Care Quality Commission’s finding that one in five NHS Hospitals are neglecting elderly patients to a criminal extent was compounded in November 2011 by the Equality and Human Rights Commission report, which reveals that thousands of elderly people in England receive care services at home that are so poor their human rights are being breached.

Denying that budget cuts have any bearing on these findings, Care Minister Paul Burstow side-stepped questions about care staff receiving the minimum wage and told the BBC that “this is what happens when you have people who feel they can switch off their basic humanity and compassion when they cross the threshold of someone’s home to provide what should be decent quality care…”[1].

Clearly we need to ask why, beyond an inevitable few bad apples (a recruitment issue), an alarming number of nursing and care staff fail to respond to patients and clients with empathy and diligence. Equally, we need to recognise that the practical shortcomings of poorly resourced, target driven care, which are very much in evidence in recent reports on care standards, may be having an insidious impact on staff motivation and professional integrity. A consideration of the effects of shame, an emotion that is ubiquitous in human interaction but rarely acknowledged, may help us understand current failings in provision, which the CQC attributes to ineffective leadership and poor staff attitude.

Those staff who feel that nursing the elderly is beneath them may be experiencing shame, exacerbated by a culture that places value on financial and time-driven targets at the expense of the physical and psychological wellbeing of patients and staff alike; that fails to trust staff to function competently, creatively and with initiative, and to reward them adequately.

Shame involves a negative evaluation of the self as bad or not good enough. It pulls us back from engagement with the things that interest and motivate us. It can lead to a loss of moral agency and professional integrity. In the grip of shame, we can lose interest in our work, and at times our values. We may feel powerless to change our situation or to challenge a situation that we know is wrong. This may in part explain why some care and nursing staff neglect to do their jobs well.

For instance, with budgets in some local authorities so restricted that carers are limited to 15 minute stints in an elderly person’s home, carers may be forced to meet externally determined deadlines at the expense of responding to the legitimate needs of clients. Laying the blame for neglect entirely on care staff fails to address the lack of congruence between the varying care needs of individuals and an under-resourced and inflexible provision. Such an approach is fundamentally shaming and demoralising to those staff who would prefer to do their jobs well.

In a society which expresses value through financial reward, paying care staff the minimum wage can only reinforce the lack of value placed on this work by government ministers and care providers. In part what it exposes is gender inequality, the legacy of a patriarchal culture in which caring for the elderly and vulnerable has traditionally been undertaken by women. There is no longer any excuse for this and we cannot afford to underestimate the correlation between low pay and poor self-esteem – a corollary of shame.

Additionally, shame leads to resentment and hostility. The less staff are valued and respected by their managers and community, the less they are likely to value and respect the vulnerable people in their care. Conversely, leadership, training and remuneration that demonstrate a genuine respect and value for staff and for the individuals they care for, will foster pride and high self-esteem, providing a buffer to shame.

It is too easy to lay the blame for neglect on carers rather than the budget and system inadequacies that make care work an occupation to feel ashamed of. Effective leadership is crucial to restore pride and social capital to care. Care providers need to promote the vital importance of fundamental care tasks and to foster, through their mission statements, policies, recruitment, training, and budgets an authentic and above all empathic approach to caring for elderly and vulnerable human beings.

© Miryam Clough 2012




[1] ‘Care minister Paul Burstow on Elderly care report’, BBC News 23.11.2011, http://www.bbc.co.uk/news/health-15854448, accessed 23.11.11