Is Workplace Culture an Excuse for Poor Care?
Hello to all our nursing friends around the world. I know wherever you may find yourself out there, you are doing your best for your patients and work as a team with your colleagues. In our previous post “Lack of respect for the nursing profession?” we explored issues why nurses does not enjoy the high status of other professions as they should.
Today we will look at workplace culture. Is it possible that our workplace culture can affect the care that we give to our patients? The answer to that is yes, it can. But that is not the whole story. To get a better perspective, and dig deeper into the concept of workplace culture, we will explore some of the findings of the Francis Report (referred to as Report hereafter) published in 2010 and 2013. In brief, the Francis Report is an inquiry about the care provided by Mid Staffordshire NHS Foundation Trust between 2005 and 2009. The inquiry that led to the report cost £13 million. It shook the healthcare system in the UK and send shockwaves across the world about the abuse and neglect of patients at this healthcare facility. It was a scandal and nurses were implicated. This wiki page gives a good overview if you like to get a broader perspective.
Lets look at the issue of nurses’ own responsibility for their actions. Negative and inappropriate behavior can be explained by external factors such as culture and the influence of others, or by our own internal moral framework. The Report suggests that culture was the problem and proposed changes to management and leadership and emphasises clear guidelines and education. It advised that there should be a move from a financial focus to a care focus. But what about the individual nurse in such a culture? Attribution theory suggests that people will attempt to explain away negative actions by claiming that the cause is external to them – “It was not me, it was the culture or the system”. I think many of us can relate to this – some external factors does exert powerful negative forces.
But the NMC revised code of April 2015 makes it quite clear – as nurses, we are responsible for our own behavior. Many nurses in the Stafford hospitals did perform their duties in a caring and professional way, though this did not make it to the headlines (the way these things go). The question then is, is it possible to take personal responsibility for our nursing practice regardless of the working culture? Do nurses who are unable to take responsibility for their own standards of care deserve the title “nurse”? What do you think? Lets consider one of hundreds of accounts of poor care described in the Francis report to help us work through this. The following is an account of a family member of the care of her mother.
The patient died later that night. The report has an astounding number of similar stories. Worse still, some family members invested in video capturing devices which they hid in rooms and recorded these shocking events. They are all over the internet. As a profession, these types of evidence makes a very hard case against our profession. There were other accounts of nurses being rude, callous and mocking, frail people left on commodes for hours; buzzers being ignored or disabled; and general incompetence. There were incidences of very poor hygiene, inadequate record keeping, poor organization, poor communication, falsifying notes and wrong administration of medication.
Culture, causal attribution and behavior – Attribution is a theory from cognitive psychology that attempts to understand the human tendency to attribute motivation and cause of behavior. Heider (1958) suggested that there are two main types of attribution – dispositional and situational. Dispositional are those causes that are within a person whereas situational causes are external to the person. One makes a judgement about a behavior according to whether the causes are perceived as either internal or external. Heider said that a person tends to perceive negative behavior in another as dispositionally caused (she/he is like that) whereas ones own negative behavior is likely to be described as situationally caused (I had no choice, the manager told me to do it, the ward culture was like this, I was following orders etc.). In other words; if others are displaying negative behavior we ‘blame’ it on them. When we are displaying negative behavior we blame it on others (including inanimate objects – the room was too small). If culture is being blamed in the Stafford hospitals, then a situational attribution is being sought as the cause.
What of the nurses in such a culture? Davidhizar and McBride (1985) suggested that student nurses saw the tasks they had to do as externally located and stable and their effort as internally located and unstable. This has implications for the confidence of nurses when they rely on their unstable resources to challenge what they see as stable cultures. On the other hand, Meurier et al (1998) offer some hope. They suggested that, although people generally explain unpleasant events or their role in them on external (situational) attribution and are therefore less likely to learn, nurse are more likely than is typical to blame the error on internal (dispositional) factors. This suggests a strong professional ethos and some hope for being able to care in the context of uncaring cultures.
Obedience to authority – Milgram’s famous experiment (Milgram,1965) explored the extent to which people were prepared to hurt others simply because they were told to do so. He found that 65% of participants were prepared to inflict severe pain just because they were told to do so. Many of the participants felt extremely uncomfortable but, as far as they were aware, inflicted the pain anyway. If 65% of Milgram’s participants were prepared to inflict pain on a stranger, then it is also true that 35% were not prepared to do so. What did this third minority have that the other two thirds majority did not? First, they had a sufficient sense of right and wrong and the assertiveness to behave accordingly to what they know is right.
The shocking stories in the Francis report lists 31 stories from the first quarter of 2005 and, of these, 15 were negative and 16 were positive. In other words, whatever the culture, half of the nurses managed to behave as nurses should and half did not. Regrettably, the shocking stories will dominate the headlines and discussion. When things go wrong, we tend to focus on that. What is your thoughts about this? Should it be so? Should we not also focus on the positive aspects and build on it? Think about that for a minute. How often in your practice, is either a group or individual praised for their good work, and how often to you have meetings to discuss what is wrong. Is there a balance? Reflect on this and take action, and make suggestions.
The shocking stories in the Francis report lists 31 stories from the first quarter of 2005 and, of these, 15 were negative and 16 were positive. In other words, whatever the culture, half of the nurses managed to behave as nurses should and half did not. Regrettably, the shocking stories will dominate the headlines and discussion. When things go wrong, we tend to focus on that. What is your thoughts about this? Should it be so? Should we not also focus on the positive aspects and build on it? Think about that for a minute. How often in your practice, is either a group or individual praised for their good work, and how often to you have meetings to discuss what is wrong. Is there a balance? Reflect on this and take action, and make suggestions.
As a professional, you are personally accountable for the actions and omissions in your practice and must always be able to justify your decisions (NMC, The Code, 2015). Within the same hospital culture, it seems that some were able to take responsibility and some were not. One vignette, describes the despair of a nurse who was trying to take responsibilities for her actions:
It is probably the case that many nurses of al branches feel that they work under conditions and in cultures where it is difficult to truly perform the duty of care. Do you agree? Do you work in conditions where you feel you cannot do your best due to circumstances out of your control? Some of us believe that conditions are worsening, with cuts and fragmentation, to create and environment (culture) where scandals are more likely.
The Francis report made recommendations for a change in culture and service to ensure that the events at Staffordshire Hospital are not repeated. Reviewing nurse training, greater transparency, mission statements making expectations clear, putting patients first in planning services and developing leadership are all critical tools for a culture of change. But what can you, as an individual practitioner do to prevent these sort of things from repeating themselves? Review and reflect on your moral compass – adjust and align it if necessary to the NMC Code. Raise concerns if you feel that systems are unsupportive as they often are in these cases. Few of us like to stand out and be unpopular but some nurses are prepared to do so. We can all decide where we stand on this continuum and draw our own line. In the end, cultures are only a collection of individuals.
Source: Is Workplace Culture an Excuse for Poor Care? Steve Mee, Senior Lecturer, University of Cumbria, Nursing Times, Issue 109, #13, 2013.