Knee Jerk Reactions and Deja VU

My English A level teacher at school had a degree in History from Cambridge.  When I enquired why he was now teaching English, he said he now taught English "because sadly humans never learn anything from history".  I remember as a 16 year old thinking to myself, he's both astonishingly cool and totally cynical.

So, was he right?

I think that now, after all these years, I can finally see that he was not only correct, but astonishingly so.
In the care sector, I find it incredible that we haven't learned the following 10 simple truths.

1. The immediate  knee jerk response to a problem is often pointless and counterproductive
2. Not everyone knows what they are doing
3. If you need people to follow the rules, tell them what the rules are in simple unequivocal language and then explain what the purpose of those rules are
4. Often rules in care homes are pointless, arbitrary and through word of mouth causing needless anxiety and conflict
5. If you apply a lot of pressure to people, they don't always do the right things at the right time
6. If you don't treat your staff well, then chances are, they won't treat the people they are paid to support well either.
7. Everyone is to blame, but no one is responsible
8. All organisations think it will never happen to them
9. Training is a core element of your staff development and an investment not a cost or a burden
10. Every organisation needs a Leader

Further I'm also becoming increasingly depressed that every time there is an expose of poor treatment of vulnerable people in care people seemed to be "shocked".  I wonder why it is, that something that happens so frequently has the ability to shock people?  Let's look again at humanity and discover when we should be shocked by the way we treat each other.  Why are we more shocked by a man slapping an elderly woman than we are by someone who lives on the street because they've lost their job and have a severe mental health problem.  What about the child who's bullied at school and goes home every night wanting to die because they can't go on?  What about the 1million other elements of human behaviour that are less than human?

The reality is that we will never stop the abuse of people in care, but, if you put a good system in with strong leadership and appropriate training, then you will certainly diminish the likelihood of it happening.
 

What’s it like to be constantly observed?

For this exercise, please imagine what it would be like if you lived with someone who will make tea for you, take you to the shops, come over and chat to you 24 hours a day, 7 days a week.  Sounds good doesn’t it?  Well it might sound better if the person doing this is one of your choosing, maybe someone attractive or who you get on with and you could ask them politely to push off when you wanted some time on your own.

Sadly, you are living with a carer you didn’t really choose, they often change every eight hours and sometimes some group called “the agency” send someone over, in fact you’ve never met them before and they only seem to know your name and nothing else about you and you think he’s called “bank” or something.  It doesn’t matter though because “bank” won’t be here next week or perhaps even tomorrow.  He’s off to see another “client” or someone who uses stuff.  He must be important though because he often turns up dressed in some sort of uniform.

Imagine living in an environment where your every hour was documented. Not only did people check and note whether you slept well, but whether you'd had a bath, brushed your teeth, shaved, whether it was your period or leading up to, whether you’d had a good poo or whether you’d engaged in any “sexualised” behaviour.  Imagine there was a plan to manage your “sexualised behaviour” which was designed to stop you having any pleasure?

What if years ago you used to get angry because you couldn’t do things you wanted to and got frustrated?  How might it be if you were labelled as “challenging” from that point until the day you die?  Even though the reason you were angry was that you weren’t allowed to go to the toilet when you wanted or have a cup of tea when you wanted. 

Let’s imagine it’s you!

Scenarios you might relate to

1. The tram you take is replaced by a bus service which makes you late for work 3 weeks in a row.  Your manager writes it down in your work file.  Seems reasonable doesn’t it, after all they might need to monitor timekeeping as you’re paid by the hour. 
1. Now imagine that you were then labelled as poor timekeeper until the day you retired and nobody took into account it was the tram that was the issue not you?  What if for some reason you had moved jobs, but they still referred to you as a poor timekeeper?  In fact, you weren’t even aware that you were changing jobs until the day you were just dropped off at a different workplace (day centre).
2. You are seen shouting and getting angry at someone because they are about to break your favourite object.  It gets reported by a person you vaguely know to your boss, then it goes in your personnel file and the recommendation is that you attend anger management sessions to deal with your anger issues, but no one tells you why?
1.  Now imagine that if you don’t “control” your anger you won’t be allowed to go to the pub tonight or for a drive over the weekend.  In fact not only does it go in your file, but, anyone who has a vague responsibility to you also knows about your “anger issues”.  They might even have a meeting between some people (multi-disciplinary team) you’ve never met to discuss what’s best to do with you.
2. You’ve also noticed that not only do you have one carer but often a much bigger carer comes with them to “help out”, he’s not quite as friendly as your usual carer though and you don’t trust him.  Wouldn’t it be nice if you could avoid him?

How would someone view you if the information they received about you was written many years ago and had never been changed or updated?  Imagine if as a 45 year old, all the documentation about you was written when you were 25 years old?  What would it say and how would it be different?

What if you disagreed with these assessments of your personality, but had no ability to change the documents?

Welcome to the world of adult residential care! 

The BILD Factsheets, from BILD, the British Institute of Learning Disabilities

The BILD Factsheets, from BILD, the British Institute of Learning Disabilities

A series of informative fact sheets from BILD which summarise items which people working in Learning Disabilities ought to know, but often don't!

In particular for those working in Elderly care can I draw your attention to the Fact Sheet on Chemical Restraint.

Study suggests that more qualifications and more support increase social worker resilience | British Association of Social Workers

Study suggests that more qualifications and more support increase social worker resilience | British Association of Social Workers

Very interesting study which we will be keeping a close eye on.  We are especially concerned with the support element of the article.  Although we are a training company, it's all too often that both training and courses fail due to lack of proper setting conditions in the workplace.

Personalisation, Positive Approaches and the role of Staff

Often when we run training, we ask staff members a simple question, with regards to their jobs.

"How do you wish to be seen by the following groups"

• Your employer?
• The people you support?
• The public?
• Your family?
• Your colleagues?"

This might seem like an obvious question, and in fact, many of the responses we get are what you'd expect.  In general the responses received would be along the lines of "professional, empathetic, competent, calm and knowledgeable".  This is pretty obvious stuff.

However, we then ask a second question.  This question often requires us to let them know it's confidential, we won't tell their managers and we won't mention any names.*

 "How do you think you are really seen by those groups?"

This is where the wish to be seen in a particular way, diverges from the reality of how they are seen.
Sadly the responses we get are often heavily negative.

1. My employer doesn't trust me, I only see my manager when I've done something wrong (or they think I have).  I'm not listened to, I don't get support and if something goes wrong I'm blamed!  My employer thinks of me as the enemy.  I get positive input when I'm asked to do an extra shift.  My ideas are never supported.
2. The people I support see me as caring but don't often understand why I'm doing things, or why I can't let them do things.
3. The public think I abuse people in my care and that I'm not really anything more than a bottom wiper.  They think that people in care are either neglected or abused and they don't realise how hard it really is.
4. My family (unless they work in the field) have no idea why I do this and don't understand why I don't work somewhere with more money.  If they work with people who challenge, they will often be asked why they don't just "hit them back".  My family can't get their heads around why I would never do that.
5. My colleagues think roughly the same as me.  We are doing our best with very few resources or often any real idea who to do things.

For us, this leads to a dilemma of massive proportions.

Most of the current training in the social care sector centres around the concept of positive approaches to the people we care for and developing services that are personalised.  We are supposed to treat people as people, not use derogatory words, and not to dehumanise them.  At least that is what the training and guidance would have us indicate.

So, why is it, that this sometimes doesn't happen?  As with all things, training is only one half of the story.  For good training to be useful or indeed for it to achieve what it's supposed to,  it needs a clear support system in place.  It needs the setting conditions for success.  It needs to be reflective of the organisations philosophies and it needs to reflect the way the organisation is run.

It cannot contradict the underpinning concept of the training.  For example, if you expect a member of staff to treat a service user with compassion, understanding, empathy and in a professional manner, but, then you treat the member of staff as if they were a child who is not able to understand, you

• dictate rather than engage,
• shout rather than speak, 
• instruct rather than explain and most importantly in this relationship, if 
• gloss over and just give them a printout or a "policy" rather than educate and get them to understand what you want.

 Then, you as an organisation are failing to continue the chain of events that needs to be followed.  We need to ensure that if Staff are going to have compassion and understanding then that really needs to be the way they are treated.  Learned behaviour is one of the most powerful tools around.
 The relationship between all the parties in care is complex, the service user should be at the heart of the chain, but, each link is only as strong as the weakest link.  These links would consist of

Owners - Managers - Staff - Families - Inspectors

All leading towards

The people that we support

So what are these setting conditions that avoid the chain becoming fragile and the process breaking down?

• Supervision which is designed to coach rather than monitor the person.  Coaching someone to be better at their job will engage the member of staff far more than telling them to be better.  Most managers are unaware (or seem to be) that most staff don't actually look forward to supervision, they see it as a time to get told off and avoid talking about what they don't know.
• Appropriate training linked to need and to policy.  Training that tests knowledge is far better than training that doesn't.  Training that just awards attendance or is so simple you don't need to do the course to pass is actually pretty pointless.  Staff drift off and don't place value in it.
• A debriefing system independent of line managers
• Managers who attend the same courses as their staff as a participant, not as a manager supervising their staff.
• Clear guidance which staff can understand and follow.  
• Don't stop learning!  Organisations who believe they know everything and they haven't got any issues are often the ones in the most trouble. 
• Use positive approaches as a theme for your organisation at every level, not just expect the staff to exhibit it when dealing with those in their care.
• Use personalisation all the way through your organisation, each person works better when they are valued irrelevant of who they are.
• Reward people for doing a good job.  Often, don't take them for granted and be nice to them. 
• People always work better for those they want to work for, not those they have to work for.
• Place value in your staff and they will place value in your organisation.
• Learn.

If you think your organisation is getting it right, then that's great. If it was my organisation I'd personally sing it from the roof tops.  Do a 360 review with hard questions asked, I'd bring in advocates and get them to ask the people we care for what they think.  I'd then put it on all my advertising and make it public information.  However, if you are worried about the outcome of a review, or you'd not want to publish the results, then, it might be an idea to do something about it.
 

Maybe a better question should be,

"Would I be comfortable with a Panorama journalist working undercover in my service?"




  *Unless of course something is happening which is illegal or unethical in which case obviously we have to pass things on.

"Don't Call Me Dear"

Recently there was  some guidance published by the Commission on Improving Dignity in Care which according to certain media suggested that if you called a person you were caring for "dear" it was belittling and you should be sacked.  I suspect that this mixing of messages was more to do with journalism than the report itself which says no such thing.  Dignity in Care Report.

The report is a sensible (if at times obvious) list of things which in should form the bases for every care home and hospital's approach to working with those in their care.  Referring to people obliquely or directly as "bed blockers" or "hip patients" dehumanises the patient and can allow for the instigation of a unintentional abusive relationship between carer and cared for.  Often the first stage of abuse is a change in the power structure, with one group starting with power and then increasing it by reducing the power continuously of the weaker group.  One simple method of doing this, is to refer to the person by a feature, attribute or condition.  None of us wish to be discussed solely as an illness or a personality disorder, we are people with an illness. 

Some of the recommendations are astonishingly obvious, but often just don't happen in the day to day running of a hospital or home.  As an example, you'd think that training staff to understand dementia is a given, but it so rarely happens even in units that are supposed to be specialists in dementia care.  It's all well and good having a senior management team who've got loads of qualifications in dementia, care, understanding behaviour and principles of personalisation, but if you're direct care staff have no idea what they're doing, then it's pointless.

Encouraging relatives and family to feedback and engage in the process is often blocked by organisations who are uncomfortable being scrutinised.  It's simple enough to do, it's hard to put into practice without becoming defensive about the service you provide. 

However, let's not lose sight of the fact that care staff are also people and need to have some form of coping mechanism in dealing with what can often be a very distressing job.  How often does a member of A&E staff have to see a dead child before it has a massive impact on their mental health?  How often does a member of staff in an Psychiatric Ward have to see a person with horrific scaring from self harm before they become immune to it?  How frequently does an Oncologist have to see a child or adult suffering and intense pain from cancer before they find a way that helps them cope and sleep at night?  All of us will use humour as a coping mechanism and medicine is no different, the problem is that this humour rarely translates outside of the job. 

The guidance given makes perfect sense, it's succinct (so rare in this day and age of guidance), logical, easily absorbed and most importantly humanises those who might be dehumanised.  But, and it's a big one, let's not change demonising patients to demonising those who care for them.

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.