As the Francis report has indicated, many of the most serious failings of the NHS are in personal care. But if we don’t value it enough to try and understand it we may not be able to provide it, write Susan Procter and colleagues

We talk about care but what does it mean? 

The Francis report has identified fundamental challenges to the culture of care in the NHS. When we talk about care we all think we know what it is; it is so fundamental that any serious examination of it is seen as over intellectualising a basic human attribute.

But do we know what care is? When was the last time you actually had an honest and in-depth discussion about what care means to you? 

Research in this area makes a distinction between care at the personal level and care provided by communities and societies.

‘It is in personal care that many of the most difficult ethical and moral dilemmas of service provision are located’

Care by the community and society is associated with the more generalised, redistributive and supportive functions and treatments provided by health and social care. These are legitimised as areas of public concern, debate, research, policy initiatives and investment.

Personal care includes the more intimate forms of care associated with assisting with bodily functions and individual needs such as bathing, elimination, feeding, providing company or showing concern.

The intimate aspects of personal care have traditionally been provided by families and are therefore rarely debated as they are consigned to the private sphere of family relationships. 

Understanding what care means

As the Francis report has indicated, many of the most serious failings of the NHS are in the realm of personal care. It is here that many of the most difficult ethical and moral dilemmas of service provision are located.

They are difficult because rather than there being a continuum from care by the community to personal care within which the intimate care associated with nursing can be located, a number of writers have suggested that the two forms of care are fundamentally incompatible.

The importance of understanding what we mean by compassionate care is reinforced by Health Education England. In their strategic document it says:

“It is vital that we encourage greater innovation and research, but there’s little point investing in research and development and technology if our staff do not have the skills to use them. Most important of all, the NHS could employ hundreds of thousands of staff with the right technological skills, but without the compassion to care, then we will have failed to meet the needs of patients.”

‘If we don’t value care sufficiently to try and understand it we may end up not providing it’

It is and will remain important that the problems at Mid Staffordshire were first detected by the identification through audit of a higher than expected mortality rate.

This reinforces the importance of monitoring and audit as a method of scrutiny and one which needs to be maintained. However, monitoring and audit as a vehicle for management will not prevent “another Mid Staffs”, it will merely detect it after the event.

If we are to live up to the aspirations of HEE, the debate that follows the Francis report needs to recognise the importance of understanding what we actually mean when we use terms like “care” and “compassion”.

While care maybe fundamental to being human, if we don’t value it sufficiently to try and understand it we may end up not providing it. The following case study illustrates these issues.

An elderly patient had recently been admitted to a 30-bed elderly care ward. The incident was observed during the course of an evening shift. There were three care staff on duty: a qualified nurse and two healthcare assistants.

The patient was unhappy about admission to the ward and repeatedly told the care staff she wanted to go home. She lived by herself in an isolated rural setting some distance from her family. It was the middle of winter and very cold. Her family did not think she could manage alone at home and were instrumental in getting her admitted to the ward.

After a few hours of repeatedly explaining her desire to go home to which the care staff listened sympathetically, the elderly lady walked, using her zimmer frame, to the ward doors in an attempt to go home. The ward exited on to the perimeter road of the hospital. The care staff caught the patient at the second set of doors. The patient refused to return to her bedside. The care staff cajoled, encouraged and explained why she needed to remain in hospital but to no avail, and eventually they physically returned the patient to her bed. The patient immediately repeated the exercise.

One HCA guarded the ward doors, while the nurse rang the patient’s relatives, described what was happening and asked them to talk to the patient, which they did to no avail. The situation continued to occupy two and sometimes all three care staff for the next hour.

Other patients were being neglected. In the end the nurse reluctantly and apologetically removed the zimmer frame. The patient protested long and loudly about this. The ward staff were busy catching up with the neglected needs of the other patients.

After a while the patient needed to go to the toilet, she was unable to get there without her zimmer frame, neither could she attract the attention of a nurse or HCA and eventually voided on the floor. The ward staff expressed their exasperation at her behaviour as they cleaned her up and mopped the floor. The patient looked humiliated. As the care staff were going off duty, the patient offered them some chocolate as a token of reconciliation. The care staff refused the chocolate.

Procter, 2000

Absent authority figures

This case highlights the complexities care staff face when formal and informal care decisions converge. The care staff were not party to the decision to admit the patient, but they were clearly having to manage the consequences of this decision.

They were powerless to influence the future for this patient so could not enter into a meaningful discussion with her about her care and negotiate a compromise with her.

This had direct implications for the standard of care staff were able to provide to this patient and other patients in the ward. The standard of care provided fell well below what the staff considered acceptable. 

‘Because of its hidden nature personal care it is often invisible to those who run, direct and manage our large institutions’

The self-esteem of all of those involved was undermined by the decisions of absent authorative others. The case highlights the importance of care staff having the authority to negotiate with patients and enter into meaningful discussions with them, which needs to be respected by absent authorative others.

It also illustrates the importance of listening to and entering into a meaningful dialogue with the patient and their family at the point of admission and working through the risks with them. To simply admit the patient in this case against her wishes resulted in her humiliation and the neglect of other patients not seen by those who took this decision.

In other words, it results in a failing of compassionate care by those authorative absent others who took the decision to admit the patient or who agreed the admissions policies, but who remained unaware of the consequences of their decisions.

What can be done?

Because of its hidden nature personal care, the intimate, tending care given by nurses − but increasingly by untrained or minimally trained healthcare assistants − is often invisible to those who run, direct and manage our large healthcare institutions.

This is considered to be acceptable because it is after all just substituting for family care and therefore does not make excessive intellectual demands. However, unlike family care this care is being given in the public domain under strict governance processes.

‘Listening will lead to very complex emotions in the listener − not feelings that those running the NHS are used to dealing with’

For those in charge of these organisations to not know what it entails, what it consists of and what is actually happening on their watch is like a car manufacturer not knowing how a vital component is fitted into an engine.

Traditionally the responsibility for knowing and communicating this knowledge rests with the director of nursing. But this creates a huge translational burden and too often directors of nursing are forced to adopt rational bureaucratic language to explain emotionally charged and personalised processes and experiences.

Language barrier

There is increasing recognition of this problem and a number of techniques and strategies are being recommended. For instance Schwartz rounds have been introduced in a number of trusts. Schwartz rounds are open to all hospital staff and provide a monthly forum to explore the emotional, moral and ethical dilemmas raised by care giving in a non-judgemental conversation, creating learning across the organisation about the hidden aspects of care.

Restorative supervision is being offered in other trusts as a vehicle for staff to process the emotional burden of their work and support their capacity to question and challenge the content of their work in a “safe” environment.

Both of these depend on the ability to listen. As the case study illustrates, listening will lead to very complex emotions in the listener; they will feel anxious, inpatient, stigmatised, contaminated and confused. These are not feelings that those running the NHS are used to dealing with.

If we are to truly create a compassionate, caring NHS then everyone − particularly those at the very top of NHS organisations and institutions − need to recognise that to do their job well, to earn their salary, means they have to listen and they have to deal with the spoiled identity that may result from listening.

Dr Susan Procter is professor of clinical nursing practice at Buckinghamshire New University; Dr Sonya Wallbank is programme director, restorative supervision, at Warwickshire Foundation Trust; Dr Jagdeesh Singh Dhaliwal is a family practitioner, deputy director of postgraduate programmes at Keele University and non-executive director at Birmingham Community Healthcare Trust