Following the government’s response to the Francis report, Michael West argues why fostering compassion should not be about threatening criminal sanctions but about relieving stresses on staff
The government response to the Francis report includes two proposals that have attracted much attention: the introduction of criminal charges in cases of wilful neglect and publishing details of nurse staffing levels on each ward.
These are symbolically powerful. The first is designed to deter those who might otherwise mistreat people in their care and the second to provide hard evidence of safe staffing levels.
‘Healthcare by its nature involves a high level of negative emotion and staff need high levels of positive emotion at work’
The context of these proposals is a vast sector, staffed by an overwhelming majority whose work is − or originally was − a vocation. They want to dedicate their working lives to helping other people in pain, distress or need by using evidence and knowledge to provide the best quality of care possible.
This potentially creates powerful cultures of compassion and professionalism. Interventions should therefore be evaluated in terms of whether compassion and professionalism are enhanced or undermined.
The context is also one in which stress levels are unacceptably high among staff. After teachers and welfare professionals, nurses are the most stressed group in the UK working population. It is swimming against the tide to try to be compassionate when we feel stressed, especially when doing so leads to further stress.
Stress is not some self-generated discomfort that requires us to tough it out. It kills people. It leads to emotional exhaustion and the de-personalisation of self and others. The primary predictor of stress in the NHS is workload.
The toxic cocktail of high work demands and low control is what harms people. Many NHS staff report feeling overwhelmed by unnecessary bureaucracy, inefficient systems, initiatives and priority thickets.
‘The more we focus on enabling NHS staff to fulfil their visions and live their vocations, the higher the quality and more compassionate the care’
This is compounded by leadership failures to deal with these problems. The failures begin in government and extend through the system down to some frontline supervisors.
Healthcare by its nature involves a high level of negative emotion – patients feel out of control, afraid, in pain and miss their homes and loved ones. For staff to be attentive, feel empathy and take intelligent action for patients (the key elements of compassion), they need high levels of positive emotion at work.
Optimism, cohesiveness, humour, support and a sense of efficacy all contribute to this. Balancing negativity with an atmosphere of positivity and support enables staff to be compassionate, make better diagnostic decisions, be attentive to patients and deliver high quality care.
Ensuring safe staffing levels should help because there is evidence that nurse staffing ratios can help predict outcomes. Public information about staffing levels in each area is one instrument to help achieve this. But on its own, it is a blunt instrument without considering the following:
- leaders must focus on providing high quality care as their top priority;
- directorates, wards, teams, departments and individual staff must be clear about their objectives and have the support and resources they need to deliver;
- people management must be positive, enlightened, supportive and enabling;
- team working must be effective and collaboration across boundaries reinforced continually to ensure patients receive integrated, high quality care; and
- patient experience and involvement must be at the core of compassionate practice.
Fundamentally, we need to build the cultures and leadership necessary to deliver high quality patient care. This means staff need leadership that:
- reinforces an inspiring vision of the work;
- seeks and acts on high quality intelligence to help them deliver;
- listens and responds to patient experience;
- is fair, transparent and trustworthy;
- promotes positivity, staff health and wellbeing;
- empowers staff to solve problems and innovate;
- gives helpful feedback, supports learning and celebrates people’s contributions;
- takes action to address system problems;
- develops and models excellent teamwork;
- ensures staff feel safe, supported, respected and valued; and
- models values that inspire those in the organisation.
New leadership focus
At the King’s Fund, we are currently working with the Care Quality Commission to consider how such cultures and leadership can be assessed, thereby focusing the sector on these fundamental elements.
‘The threat of criminal sanctions will not increase compassion and professionalism’
Regulatory agencies should also model the cultures they seek to promote in healthcare organisations; their processes should promote optimism, efficacy, empowerment, cohesion and celebration. Compassion will increase as a consequence.
The more we focus on enabling NHS staff to fulfil their visions and live their vocations, the higher the quality and more compassionate the care our communities will receive.
What then of the proposal to introduce a new criminal offence of wilful neglect? While the urge to use the force of the law in the very worst failures in care is understandable, the threat of criminal sanctions will not increase compassion and professionalism.
Far better to create the conditions in which failures of this kind never occur and to provide staff with the resources and time to deliver the best possible care within available budgets.
Michael West is senior fellow at the King’s Fund