Deja Vu

Yet more abusive treatment in care

Abusive treatment of the elderly in NHS hospitals reported today by the Patient Society.  Now where have I heard this sort of thing before?

Oh, I know, Winterbourne View, Southernn Cross, McIntyre undercover report into care homes in the South East and on and on.  Will it ever stop?  Probably not. Can it be reduced?  Definitely

How though?

The reality is, that as damning as this report is, and as "horrified" as we all are and no doubt politicians and the media will now ask for an "urgent review" or "public enquiry", the answers are fairly simple.  This is a waste of time and money and has been done before.  Have a review,report,enquiry, but doing it on the people succeeding and find out why.

We need an attitude change

• People who are elderly, infirm, disabled, forgetful, incontinent, angry, sad, mentally ill, learning disabled are all defined by the first word in this sentence.  They are people.  We need to stop demonising those that aren't "tax payers" or treating people who are disabled/elderly or both as if they're a "drain" on the rest of us.  The reality is, that we, if we live long enough we will fall into one, other or both of those categories.
• Staff need to be trained to smile and greet.  It's not a five star hotel, I realise, but, if they did smile and greet, rather than avoid eye contact and scurry away from patients/visitors etc, then they'd probably encounter far less hostility from people who are confused, angry and possibly in pain.
• The public need to be educated on how a hospital works.  The nurses aren't all on lunch break ignoring you, they're often doing paperwork which may seem like a waste of time, but will probably mean that your appendix gets taken out rather than having your quite useful arm being removed by accident.  Or that they don't give you a drug that might kill you.  Paperwork is meant to eliminate mistakes.
• Someone asked on twitter, how much does it cost to learn some one's name?  Well, obviously nothing, however, patients also need to realise a number of things
• Staff might see well over a thousand patients a year and therefore remembering names is difficult and for some people they're just not that good at it
• Becoming attached to people who might die  on their watch is actually traumatic for the staff, so they develop coping mechanisms, one of which is detachment.

We need to find the best leaders in the NHS and get them to train/mentor people

• Stop demonising great leaders for earning a lot of money.  They earn a lot of money because they have got there through hard work and skill.  Let's pay them more and get them to mentor those who could be great leaders!  Show the others what they do that makes them good at what they do.  Why do some hospitals have smiling staff, motivated people and a great attitude, while others are a cesspit of despair?  Leadership. 
• Leadership is not always about the person in the top spot though, look to promote team leaders who are not only good clinicians, but good leaders as well.
• Go to The Christie in Manchester and wander around, staff smile, people are treated properly, it's confusing and intimidating because it's a hospital, but, even though it's a cancer hospital, people smile, ask how you're doing and if you look lost, will ask you if you need help! I'm sure they also have their problems, but, in my experience they are very good.

Stop looking at what we are doing wrong and move towards what's being done right.

• Let's have a review of the best performers, note what they do which can be recreated or adapted elsewhere.  Look at A&E departments with efficient systems and recreate them.
• Be positive and look to change the hospital environment to reflect that. 
• Get people to report positive care, don't just have a whistle blowing policy, have a trumpet blowing one as well!  If someone has done a great job, let people know!
• There is a plethora of research on leadership and staff motivation.  Use it!  It's not about profit, it's about training, maintaining, motivating and retaining great people.  Every great leader or clinician that walks out of your hospital is a tragic loss.  These are the people we need in every walk of life.  People with charisma, intelligence, focus, purpose and most importantly empathy.

We need to stop looking at hospitals as a purely clinical environment

• We have spent years treating the whole of the NHS as if it's the waiting room of the A&E department.  In the media it is all about MRSA and waiting times, this has lead to all the focus being on cleanliness and getting people in and out quickly.  The reality is, often those people who are coming in are intimidated by their surroundings, intimidated by the intelligent people in white coats and scared because there is something wrong with them.  If they're also confused due to illness, age or disability then these problems magnify.  
• If you feel powerless over what's happening next, then, no experience is going to be positive.  Patients need information about what's happening and when that might be the case.
• I realise that you can't give exact details about when the doctor might get there, but even that is important to tell the patient, keep them informed and treat them the way you'd wish to be treated.

Secret Shopper

• A simple suggestion would be to get the head of every department in the NHS to be admitted to another hospital as a secret shopper to find out what it's like.   
• Have them go as a potential patient or as a relative or perhaps even just walk in the front door.
• Staff in hospitals forget that people arriving at hospital don't have the same experiences as them, they are at work, like the rest of the working population, going to work is often an emotional drain, and might be stressful, but you know roughly how your day is going to pan out, a patient on the other hand is reliant on a vague schedule that they have no control over.  
• I suspect that this idea alone will improve hospital treatment of patients massively.

Tip of The Iceberg!

How does abuse happen in care?

The recent exposure of Castlebeck on the BBC in the Panorama Documentary has highlighted a number of major issues in care which are neither new nor surprising.  The subsequent media exposure has lead to a flurry of further allegations at other homes which have been closed or investigated.

So what questions should we be asking?

• What setting conditions do you need to have a situation where this kind of abuse can take place?
• Is this unusual across all care settings?
• Where were the systems which would prevent this?
• Is the profit motive to blame?
• When the media eye is off, what happens next?
• What happened after MacIntyre Undercover almost ten years ago?

I will try and deal with some of these over the next few blogs.  The first one I want to address is setting conditions.

Setting Conditions

Most people were rightly horrified by what they saw on the recent television documentary, however, this sort of abuse is not new to human beings.  There have been countless stories over human history of how the vulnerable, weak and disenfranchised are picked on, bullied, abused, moved, hidden away and in the very worst cases, exterminated.  When these are exposed, people on the sidelines are horrified, but, it will happen again and we will be horrified again.
Let's take some examples to a greater or lesser extent have caused revulsion and horror but are repeated again and again

1. The Holocaust where more than 11 million people were executed by the sate apparatus (1940's)
2. Ethnic Cleansing in the former Yugoslavia (1980'-90's)
3. Ethnic Cleansing in Rwanda (1994)
4. The Milgram experiment/Stanford Prison experiment (1960's)
5. Abu Ghraib prison abuse (2004)
6. MacIntyre Undercover exposure of abuse in care homes (2004)
7. Castlebeck abuse on Panorama (2011)

 It may seem strange that I would include mass murder as an equivalent to the two cases of abuse in care homes,  but I'm not talking about numbers involved or the extremes of what took place, I'm talking about setting conditions and the subjegation of one group by another.  Let's not forget either that in ethnic cleansing, often the "mentally subnormal" are singled out for special attention.

All of them have some things in common.

• One group seeing another group as being a burden or troublesome
• One group being more powerful than the other
• Arbitrary rules and regulations being imposed to control the weaker group
• The ability to enforce those rules
• The belief that the other group are a separate entity to you and not as important
• The potential for promotion or increase in social status within the power group if you follow the "rules"
• Some participants in abuse being "forced" into it to maintain their social standing/employment position or safety.
• Dynamic leadership who approve of the behaviour and have a high social status in the group.
• The abusers often feel vulnerable themselves and their power can only be exerted on those more vulnerable than them.
• The abusers wanting to please their "superiors", this doesn't necessarily mean those at the top, but those perceived to hold power. 
• A lack of empathy/understanding of the other person/group

So what happens?

In my experience of working as a trainer at both good and bad care establishments, much of this process starts with two or three key things which then snowball into potential problems.

Firstly - Employers treating their employees as second class citizens without proper training and support. If, as a manager, the only time you ever see your staff for a one to one meeting is at the following times; They've made a mistake, someone has complained, supervision, to tell them off, then don't be surprised if that member of staff sees you like their old head teacher.  You are the enforcer, they don't want to see you, they don't feel suported by you and they're scared of you!
Therefore, if your employment atmosphere is where bullying, telling off, treating one group as inferior to another exists, then don't be surprised if this isn't reflected in how those staff treat people in their care.

Secondly - The creation of a set of innocuous  sometimes unwritten rules which give power to care staff over the minutiae of peoples lives, when they get up, when they drink, when they eat, what they wear, where they go and when they can go there, what they eat and in some cases in my experience, when they're allowed to go to the toilet.

Thirdly - The strict enforcement of these rules and any dissent will be treated with some form of punishment or sanction, which might be getting "told off", shouted at, having privileges taken away, being not allowed to go out or being restrained by up to 6 members of staff to teach people a lesson. 
   Examples
Some examples I have experienced in the past two years of arbitrary rules being enforced to make the life of staff easier.

• A patient being told that it wasn't 2:30 when they asked for a cup of tea at 1pm (while staff member is stood drinking a mug of tea)
• A service user being told to get out of bed at 7:30 am because it was time for staff handover
• Elderly care residents being moved from one room to another because it was 3pm
• Elderly care residents being put in their pj's at 6pm because it was easier for night staff.
• A service user being told he could only have 2 biscuits with his coffee - when he asked why, he was told " because I said so" - member of staff as eating a box of biscuits at the time
• A 40 service user being told they couldn't go out because they'd been "naughty" the day before.
• In one instance I observed a trainer explaining to staff how they could apply a "discomfort/pressure" hold to "teach children" not to be naughty.  When he was questioned about this by a teacher, he stated "well if you don't teach them a lesson now, they'll never learn!" - These children were 6 and had learning disabilities.
• A man being told (who lived in his own flat with support) that if he carried on masturbating they would stop him by restraining him and moving him to another room.

These may sound like fairly minor things, but remember, we have been in theory moving towards person centred planning in learning disabilities for at least 15 years, why is it then we are still not there yet?
I have also balanced these between public and private sector situations.

Our research

We did some research in care homes a few years ago and a full 10% of respondents (out of 200) felt that it was appropriate to restrain people who didn't follow instructions.
10% responded service users could be restrained when they shouted or were rude!


How do we create positive setting conditions?

Start with a good working environment, where staff are valued, trained, educated, supported, observed, rewarded for doing the right thing and encouraged to be allowed to make mistakes and learn from them.

• Look at all your rules and ask why they are there?  Do they have a purpose?  Do they enhance the lives of all? 
• Truly consider the purpose of your organisation.  What is your aim, keep it simple, keep it achievable, and follow it!
• Make sure every single member of staff understands and is working towards that purpose.  If someone doesn't understand, or doesn't feel included, don't be surprised if they do their own thing.  
• There's no point having a mission statement if the only backing for it is at board level.
• Give clear instructions to staff that can be justified and understood which have purpose.
• Involve staff in all aspects of the organisation - people who feel responsible for their organisation are more likely to be involved in it's progress
• Don't blame "health and safety", explain why things are in place, if you as a manager aren't able to explain why something is in place, you need to consider whether it should be in place or whether you understand it.
• If there is a knowledge gap, fill it with appropriate training or information, make sure everyone understands.
• Revisit time and again, just because you don't have a problem today, doesn't mean you won't tomorrow, constantly revisit and examine.
• As a manager if you have a skill/knowledge gap, fill it
• If you expect your staff to use possitive reinforcement and person centred planning, then you need to reflect that in how you work with them.

Finally

If you think you would never behave this way or take part in abusive behaviour, answer the following questions honestly.  It is all a question of degree.  Remember, plenty of social experiments have demonstrated that given the correct setting conditions the majority of people would take part in the abuse.

• Have you ever picked on/made fun of/mocked someone who wasn't as bright as you or part of the "in group"
  
• Have you ever bullied anyone who didn't have the ability respond?
• Have you ever told anyone what to do, not because it was the right thing, but because you could?
• Have you ever been part of a group which mocked someone else that may have caused them to be upset enough to cry?
• Have you ever shouted someone down so they backed off?
• Have you ever deliberately ignored someone who was then excluded from your social circle?
  

When you answer these questions, don't think about what you believe is the "right answer" or the last week or so, but, think about your entire life and when you were at your worst.

Human beings are a strange crowd by nature and do often "pick on" the most vulnerable in their pack, but given the right conditions this "picking on" can be limited and won't develop into something worse hopefully.

Insolvencies up Care Down!

This is a subject close to my heart.  As a trainer, I often deliver courses which require an annual update.  In some organisations I never deliver an update because all of the original staff have left and I only ever run induction courses.  In other organisations with a positive approach not just to their service users but their staff I see the same people for many years running.

Yesterday there was an article published www.publicfinancenews.co.uk about the increase in insolvencies in the care sector.  A 49% increase in the first 6 months of this year!

This normally brings a rash of arguments against private sector being involved in the care industry.  It doesn't however address some of the issues as to why there is currently a problem.  In any blame structure there is a normal willingness to blame everyone else for your problems (something most of us were discouraged from doing as children).  This article is no different in that it lays much of the blame on the current "climate" of cost cutting and poor economic factors.  It doesn't really address some of the major issues which affect all areas of care both public and private sector and that's the huge turnover in staff.

For example, it would be interesting to note that while there is no doubt that Southern Cross (as one example) did have an issue with an increase in rents, they did also have another common issue that created a series of problems.

• Staff turnover was reduced by 3.6% to 26.3% by December 2010
• Average staff pay: £13,855.96
• Number of staff : 36,699

Source here: source

Now, by my calculations, if they were experiencing a 26.3% staff turnover on 36,699 staff then they are losing and recruiting on average 9,500 (approx) staff per annum.

Now, let's assume that all of these staff needed to be recruited, trained, interviewed etc by Southern Cross, then, we can also assume that this cost a significant amount of money.

One estimate given to me is for every £1 spent on a persons salary at least £0.20 of that is made up in their first year of recruitment, training and development, some would say that is a low estimate.


This money would be both direct  in terms of paying a trainers to train and indirect in terms of paying a manager to interview at least once when they could have been managing their service instead.

• Recruitment, advertising and agency costs
• Administration of the resignation, recruitment and selection process
• this would include the interviewers salary for interview, preparation etc
• Lost knowledge and skills of departing employee
• Lost productivity of vacant position
• potentially bringing in temporary/agency staff to cover
• Induction training for the new employee
• including the cost of CRB's
• Lower knowledge and productivity of new employee during training
• mistakes made, wasted time
• The impact of employee turnover on care and staff relationships
• As mastercard would say "Priceless"

Once you take into account these costs and the added cost that every 4 years they essentially have a totally new staff group, it's hardly a surprise that there were difficulties.

So, how could/should organisations reduce staff  turnover?  This is where care organisations should be looking at the other sectors which are successful in retaining staff.  What do they have in place?  What do they do to encourage people (especially good ones) to stay?

It's not always about the money!

If you;

• treat people well
• train them appropriately
• don't treat them like the enemy
• encourage rather than punish
• listen rather than dictate and
• treat them as you would wish to be treated were you doing their job

then, perhaps we could reduce turnover and save a fortune as well as creating a long term consistant, happy workforce who connect with the people they're trying to support.

Standards of Care

We have just had a massive exposure of abuse at a Learning Disabilities Hospital in the South West of the UK followed by exposure of poor management and potential abuse cases in a large Elderly Care organisation. 
The most surprising thing to me, is that people are surprised by this.  When we ship people off to care homes and hope that out of sight out of mind is a true care model, then don't be surprised when under trained, undersupported, underqualified, undermotivated staff become prison guards.  To be honest though, having watched the recent Strangeways documentary, I'd rather have them in charge!  They seemed to be more switched on, better trained and ultimately had more empathy with the people they had a duty of care towards.  They smiled more, interacted more and seemed to be better carers.
Over the next few days we will be examining the setting conditions for both good and bad care models