Getting a grip on cruelty in care

Dr Ashworth (Questions we need to ask, The Psychologist July 2019 p.5) is absolutely right to suggest psychologists should be more directly involved with offering an analysis of abuse and poor care to vulnerable individuals in institutions. The Whorlton Hall exposure was only the latest in a line of sad stories that stretch back at least to the 1960s. We have exactly the same problem in my field of older adults. Indeed, it could be said that anybody who enters an institution is putting themselves at risk of poor care or abuse as surely as anybody who boards a plane is putting themselves at risk of crashing. As she says, what is needed is a thorough and informed psychological approach rather than a knee-jerk reaction of moral outrage, a few sackings and some sticking plaster solutions.

Psychologists could start with an appreciation of the emotional intensity involved in the work of offering personal care. Nurses and HCAs are daily close up with disease, dying, distress and injured bodies with all the attendant corporal impurities. Some of these people are still in their teens. Add to this the fact that not all patients are polite and grateful, some can be complaining, demanding, rude, racist or even physically violent. Caring work is so very different from working in an office and psychologists should be supporting staff in their difficult task. I would guess the very least we can do would be to offer time for staff to reflect on the personal and moral issues involved in caring.

We might also use our understanding of Attachment Theory to inquire whether any of the emotional idiosyncrasies each carer brings to work with them may be relevant. Parents who abuse their children rarely set out to do so. Mostly, it seems, they are under enormous stress and have little in the way of emotional resources and support to fall back on. 

Then my inner behaviourist would notice the reward structure that nurses and carers operate under. The huge demands by management for bureaucratic and governance outcomes take so much time and attention away from actual care tasks. A system that lionises non-care tasks over care tasks risks setting up a Differential Reinforcement of Other behaviour schedule that devalues care tasks. I do not mean that non-care tasks are unimportant – we all do a bit of going to meetings, research, paperwork, administration and management – but to pay attention overwhelmingly to these tasks is to collude with a system that assigns the care of individuals a low priority.

These considerations are probably helpful in understanding low morale, exhaustion and burnout amongst nurses and carers, but do not really touch on the matter of cruelty and abuse as seen in the recent Panorama undercover film from Whorlton Hall. To get a grip on this phenomenon of cruelty we have only to turn to social psychology and the seminal studies of appalling behaviour from Zimbardo and Milgram (and also the more sophisticated prison experiment replication by Reicher and Haslam). These studies, and the more recent commentaries on them (Haslam & Reicher 2017) explicitly address the genesis of cruelty, oppression and genocide. It is likely that they are highly relevant to situations where people who have entered a caring profession, presumably with some caring oriented values, are led over time to behave in ways that cause damage and distress. Zimbardo's Prison Experiment suggests we can gain some understanding of the role of intergroup conflict, the dehumanisation of the outgroup and the drift towards authoritarian behaviour. Milgram's 'Obedience' studies suggest we can understand how caring people might accept that they should behave in ways that violate their moral codes if there is a more compelling narrative.

One example from my own experience illustrates this. The Charge Nurse felt it was acceptable, unavoidable even, that an elderly spinster with very socially conservative views should be attended in her bath by a male member of staff because the ward budget would not allow for drafting in an extra female nurse. The 'greater good' of financial stringency trumped this woman's need for dignity. Arguments for the Greater Good become invalid when they result in behaviour that sullies the overall outcome. In this case, what is the point of protecting the financial integrity of a trust that treats patients so poorly?

This is only the beginning of a sketch of how psychologists might use their knowledge to offer an analysis of institutional abuse. What is needed rather more urgently is action that is practical and immediate. My hunch is that we should put our energies into supporting those nurses and care staff who are working at the clinical frontline, especially those who have some authority. In NHS  terms this would mean every charge nurse and sister, every staff nurse in charge of a shift and every Modern Matron. This is not a new idea (Georgiades & Phillimore, 1975) but it needs to be repeated over and over.

There are two main reasons for adopting this approach. Theoretically we know that the counter to group pressure is minority influence (Moscovici 1980). The situation is always fluid, and change can happen given enough persistence and energy from even a small sub-group. Consequently, we need to get alongside the group that are aiming to prioritise person centred care.

Practically we know this is already happening in many places. There is considerable variation in the quality of care offered by different wards and care homes, and often the determining factor seems to be the person in charge (e.g. Patterson et al., 2011, Section 7). I would go further and say that the culture of a ward can change from shift to shift (Wasson, 2011). Institutions and their cultures are not monolithic. If it would seems sensible to suppose that if some wards and homes are excellent and some are awful, then there are plenty somewhere in the middle that could possibly improve given some extra input.

To assist every nurse and carer (and every doctor, OT, physiotherapist, SALT or psychologist  for that matter) I would suggest we can offer some input that aims to increase the influence of  good staff and diminish the influence of poor staff. Looking through the clinical, social and occupational psychology literature I have found a few methods that might be helpful. Others with a deeper knowledge of these fields will no doubt be able to suggest others.

1. Boost self-efficacy beliefs by reminding people of their abilities, their skills, their knowledge and their experience. Too many people – dare I say it, especially nurses – lack confidence in themselves. We could be helping people celebrate their expertise and knowledge. This is especially important in morally ambiguous situations where a non-confident person may demur and allow decisions to be taken by a more confident, but misguided, person. I often use the Solutions Focus procedure of asking people to scale themselves with a number between Zero (rubbish) to Ten (Practically Perfect). They then spend some minutes talking about why they gave themselves score X and not a lower score. That is, the conversation is turned to how good, competent and skilled the person is and what it is that they are doing right. 

2. Assist the proper exercise of authority. This does not mean bossing people around but rather using a variety of power strategies (Yukl 2013, Ch. 8) to achieve good care. Plenty of good senior ward nurses are a little bit authoritarian. In particular they do not balk from asserting their authority when standards slip and performance falls short. Poor care practices just have to be stopped, sometimes with a frown, sometimes with a direct criticism, sometimes with a disciplinary action. It is always easier to do this before the poor care has become established and possibly escalated. 

3. Promote the articulation and promulgation of personal values. Nietzsche said 'He who has a why to live for can bear almost any how'. We know from social psychology (Cohen, Garcia & Goyer, 2017) and psychotherapy (Harris, 2008) that a clear statement of values helps motivate and energise. Importantly, these are personal values unique to the individual, not professional values that, however virtuous, have been drawn up by a committee. There is a useful paper on the way that personal values can be crushed out of the nursing workforce and replaced by implicit ward 'rules' that run wholly counter to the nurses' previous high standards (Maben, Latter & Clark, 2007).

4. Educate in how to motivate others. Psychologists with any therapy or coaching experience will recognise the strategies advocated by Stone (2008) intended to put Self Determination Theory to work. These are well known and should be easily practised by psychologists working on wards and taught to staff there. For example, Stone et al (2008) suggest 'Asking open questions including inviting participation in solving important questions.' This is a fundamental technique in therapy, all that needs to be done is to apply well known psychological approaches to staff as well as to therapy clients. Psychologists are in a good position to practice and promote intrinsic motivation. This stands in contrast to the prevalent trend of NHS managerialism that seems bent on squeezing the most out of workers and ends up crushing them. 

I would describe this as leadership training for ward and care home frontline staff. The target of these interventions should be the nurses and carers who are present 'at the bedside' for it is there that care is given. Good care does not happen in Trust board rooms or in managers' offices. Unfortunately the bulk of leadership training in the NHS is reserved for people who are on their way out  of clinical work or who have already left. There is a desperate need to work with nurses and carers, to work against the forces that crush their compassion and their idealism and to build on the massive reserve of good will that is too often neglected. The people who know best how to improve care on wards and in care homes are already working there and psychologists could help to make their working lives better and more rewarding, at the same time tackling head on the evils of institutional neglect and abuse.

There have been several other clinical psychologists who have thought about the state of care in our hospitals and care homes, for example Kapur (2014) and Rydon-Grange (2016). Most impressively the Faculty of the  Psychology of Older People (FPOP) produced a report in 2017 'Psychological best practice in inpatient services for older people' that could be a good starting point for anybody interested in this topic.

- Paul Whitby is a Chartered Psychologist and former Charge Nurse.  

Key sources  

Cohen, G. L., Garcia, J., & Goyer, J. P. (2017). Turning Point: Targeted, Tailored, and Timely Psychological Intervention. In A. J. Elliot, C. S. Dweck, & D. S. Yeager (Eds.), Handbook of Competence and Motivation (2nd ed., pp. 657–686). New York.

Harris, R. (2008) The Happiness Trap. London: Constable & Robinson

Haslam, S. A., & Reicher, S. D. (2017). 50 Years of "Obedience to Authority": From Blind Conformity to Engaged Followership. Annual Review of Law and Social Science, 13(1), 59–78.http://doi.org/10.1146/annurev-lawsocsci-110316-113710

Kapur, N. (2014). Mid-Staffordshire hospital and the Francis report: what does psychology have to offer. Psychologist, 27, 16-20.

Maben, J., Latter, S., & Macleod Clark, J. (2007). The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study. Nursing Inquiry, 14(2), 99–113.

Moscovici, S. (1980). Toward a theory of conversion behavior. In Advances in Experimental Social Psychology Vol (pp. 1–31). 

Patterson, M., Nolan, M., Rik, J., Brown, J., Adams, R., & Musson, G. (2011). From Metrics to Meaning: Culture Change and Quality of Acute Hospital Care for Older People (pp. 1–253). 

Rydon-Grange, M. (2015). "What's Psychology got to do with it?" Applying psychological theory to understanding failures in modern healthcare settings. Journal of Medical Ethics, 41(11), 880–884. 

Stone, D. N., Deci, E. L., & Ryan, R. M. (2008). Beyond Talk: Creating Autonomous Motivation through Self-Determination Theory. Journal of General Management, 34(3), 75–91.

Wasson, P. (2011). We've been listening, have you been learning? (The Patients Association) (pp. 1–97).

Yukl, G. (2013). Leadership in Organizations. Pearson.