The NHS Confederation’s ‘Delivering Dignity’ report is encouraging. It highlights the prevalence of ageism in British society, rightly asserts the fundamental needs and rights of older people, and recognises the problems induced by command and control leadership, and low status, task orientated care provision.
The first of the report’s key recommendations to care homes advises the establishment of a Care Quality Forum ‘to look at all aspects of care home staffing, including issues of status and pay, qualifications, recruitment, retention, development, monitoring and regulation.’ This recommendation points up issues that are key to nursing care across settings, from community and residential care to hospital wards. In order to understand why addressing these issues is crucial to the provision of high quality and respectful care, it is helpful to consider the effects of shame, an emotion that although seldom acknowledged, is ubiquitous in human interaction.
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. Shame has a ripple effect outwards from the individual or organisation experiencing it, to those within their sphere of influence. We need to recognise that nursing/care staff who do not themselves feel respected and valued may find it difficult to respond respectfully and compassionately to the elderly people in their care (‘Delivering Dignity’ p.15).
The relevance of shame to the current state of elderly care in the UK lies (in part) in the lack of social capital associated both with unqualified nursing care – reflected in low pay and poor status, and with a branch of nursing that is not hi-tech and therefore lacks glamour. It is compounded by an under-resourced and inflexible provision that is desk-led and task/target orientated (this culture has given rise to the term ‘bed blockers’), that fails to trust the judgement of those in the front line and consequently does not allow nursing staff to adequately meet the needs of their patients. This is fundamentally shaming and demoralising to the majority of staff who would prefer to do their jobs well, and who struggle to manage the tension between responding gently, sensitively and patiently to older people, who may be struggling to communicate their needs, and the pressure to meet practical deadlines – often with limited staffing.
Like Peter Carter (Today Programme, BBC Radio 4, 29.2.12) I am reluctant to accept that neglect in elderly care is wilful. ‘Delivering Dignity’ recognises there is a lack of congruence between the varying and legitimate care needs older people and current provision. It also recognises that leadership, training and remuneration that demonstrate a genuine respect and value for nursing staff and for the individuals they care for, will foster pride and high self-esteem, providing a buffer to shame and allowing them to ‘do the right thing’ for patients (‘Delivering Dignity’ Key recommendations for hospitals: 3 & 4, p.5).
We are being presented with the opportunity to restore pride and social capital to elderly care. It is time for care providers across all settings 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