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OPINION

Ann Gallagher: 'We must understand fallibility and develop moral resilience'

Can any of us be fully confident that we would never neglect a patient, bully a colleague or collude with an unethical organisational culture, asks Ann Gallagher

Findings from the Francis reports cause all of us to strive to understand what contributes to caring and uncaring nursing practices. The report emphasises that the problems are not singular. The solutions, therefore, cannot be simple.

As the Francis report says: “It was not a single rogue healthcare professional who delivered poor care in Stafford, or a single manager who ignored patient safety, who caused the extensive failure that has been identified. There was a combination of factors, of deficiencies throughout the complexity that is the NHS, which produced the vacuum in which the running of the trust was allowed to deteriorate.”

Crucially, the report requires that we question and reflect on how our core values are embedded, challenged and sustained in often frantic environments.

“It is time to work together to develop a profession that is worthy of respect and puts patients first”

The 290 recommendations are wide ranging and should be read in full. The first, under the theme of “nursing”, refers to “Focus on culture of caring” and concerns recruitment, “training and experience in delivery of compassionate care”, leadership and “constant support and incentivisation, which values nurses and the work they do”. Other recommendations relate to the training and regulation of healthcare assistants and to strengthening the voice of nurses overall. Few would quibble with these. However the devil, as they say, is in the detail and it is for us to develop this.

Our first task is to relate the recommendations to what we already know: nurses experience moral distress if they are unable to do the right thing due to an unethical organisational culture; nurses who have unmet needs are more likely to collude with uncaring practices; and a lack of ethics education, leadership and role modelling contributes to moral erosion in practice and to patient and family suffering.

Additional regulation and policing may catch out the worst “offenders”, if inspectors turn up when not expected. It will not, however, contribute to sustainable and trusted, caring cultures where patients, families and staff feel valued. This requires a bottom-up collaborative approach that engages with and implements innovations in practice and education. It will involve celebrating good practice, more resoures for ethics education and mentorship and, crucially, non-complacency.

Can any of us be fully confident that we would never neglect a patient, bully a colleague or collude with an unethical organisational culture? The Francis report offers an opportunity for us to strive to more fully understand our human fallibility and to work together to develop strategies that contribute to our moral resilience. It also requires that we commit to the flourishing of patients, families and staff. The problems may indeed be universal but the answers are necessarily local.

Good and bad practices have always coexisted and there have always been those who have taken a stand to safeguard the wellbeing and interests of patients and reminded the profession of its raison d’etre. It is time to work together to develop a profession that is worthy of respect and puts patients first, as the report emphasised.

The words of nurse WJA Kirkpatrick, writing in Robb’s Sans Everything: a Case to Answer, published in 1967, remain pertinent: “Nurses are often praised for their strength in helping other people. Needed now is the courage of truth to help themselves. Nurses must be for nursing, supporting its advances in every conceivable manner. If they do this, they will uphold the right of the sick and troubled in mind to be regarded as members of the human race; they will uphold the dignity of their patients, their own nursing profession and the National Health Service.”

Ann Gallagher is reader in nursing ethics at the University of Surrey

Readers' comments (6)

  • 'nurses who have unmet needs are more likely to collude with uncaring practices; and a lack of ethics education, leadership and role modelling contributes to moral erosion in practice and to patient and family suffering.'
    I would say that two things jump out here around 'ethics educations': one is a lack of education in that all 'study time' goes into mandatory training which is bilge no matter how hard the trainers try to make it meaningful, they are limited by CNST and sends out the message 'don't think, be corporate, obey' and the apparent lack of ethics within the ethos of Trusts to support anyone with an ethical notion in their head. Maybe there is a 'turn off' as it is hard to practise in such environments and cultures.

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  • 'nurses who have unmet needs are more likely to collude with uncaring practices; and a lack of ethics education, leadership and role modelling contributes to moral erosion in practice and to patient and family suffering.'
    I would say that two things jump out here around 'ethics educations': one is a lack of education in that all 'study time' goes into mandatory training which is bilge no matter how hard the trainers try to make it meaningful, they are limited by CNST and sends out the message 'don't think, be corporate, obey' and the apparent lack of ethics within the ethos of Trusts to support anyone with an ethical notion in their head. Maybe there is a 'turn off' as it is hard to practise in such environments and cultures.

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  • ...and don't judge people and their personality and character as bad on the basis of one simple error or an off moment, or even an off day. we all make them and all have them!

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  • Fallibility and moral resilience are all very well but an acceptance of it can breed complacency which can be very dangerous. One off errors, off moments, and off days as pointed out by anon above are understandable if out of character, correctable, and apologised for. However one of these could lead to serious or irreversible damage, say for example a normally exemplary employee is going through a divorce, gets drunk the night before a shift, is still over the limit, and misjudges a drug calculation. If the patient on the receiving end is harmed or dies do you think they or their family will say 'Oh well, it's just a one off'? Of course not! Never mind a bottom-up approach it has to be a Top-down one i.e. managers should be positive role models and encourage understanding, reporting, and addressing of neglect, bullying, and collusion. Blaming collective responsibility is nonsense as wards and units are made up of individuals. We all know right from wrong and on our individual consciences be it. There is no excuse NOT to do the right thing.

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  • "Blaming collective responsibility is nonsense as wards and units are made up of individuals."

    that is how it should be, but it goes against all the findings from group psychology and social identity theory on the influence on behaviour (much of which is subconscious) in coercive and toxic environments. I think you will agree this has been shown over and over again in past history and includes more recent events such as Mid Staffs and on some other hospital wards or department. Unfortunately there are examples, all around us.

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  • While it's true that bad practice has always co-existed alongside good practice, I would contend that something very specific has happened to influence how we now care, making poor practice much more widespread.The origins (and therefore solutions) I suggest lie mainly in the social and political realms. I've develop this viewpoint in the attached - Why caregivers have stopped caring.
    http://www.spikedonline.com/site/article/13362/

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