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Poor organisational cultures erode compassionate care


Twenty years ago, my third baby died at 34 weeks. It was a terrible shock, having had two normal pregnancies, one of which was a home birth. That evening, feeling exhausted, emotionally numb with no cot beside me, I wasn’t prepared for the well meaning midwife who came and stood at the end of the bed and reeled off Kübler-Ross’s five stages of grief.

I said nothing, let her go on, because it was more than I could do to hold it together.

This is not to be interpreted as having a go at midwives, because overall I have had wonderful care from marvellous women at various stages of all my pregnancies and for our son who arrived three years later. My point is that if one person gets it wrong that event will stand out, get in the way of the good things and remain forever in our memories. What I needed at that moment was not a parade of rehearsed facts, but more the unspoken comfort that can come from presence, acknowledgement of pain and the avoidance of being busy.

In telling this story for the first time, I want to consider the notion of compassion. We know patient satisfaction with nursing care is not as good as it should be. This is particularly true for older people. Although there are always good stories, there is often a darker side to the experience that older people have of care in hospital when they are feeling anxious and unsettled.

‘I felt the midwife lacked compassion but her behaviour was a consequence of extreme anxiety for which she needed personal support and leadership from the team’

We hear of patients being looked after in overstretched and chaotic systems where the fundamentals of care are neglected, such as nurses failing to tell patients their names, meals put out of reach and requests for help to go to the toilet ignored.

From my own recent research that set out to learn from older people about their experiences of care, patients are unambiguous about what they see as good care: “If I know what is going on, I feel more positive and in control”; good care is about having time, getting the details right and, when “everything kicks in”, respectfulness, gentleness and inclusivity. These are not big, costly or unreasonable expectations. Why then are there difficulties in getting it right?

It is not new that nursing is being berated for failing in interpersonal relationships with patients. But I for one do not buy into the nostalgia lobby who argue everything was well in the old days.

My husband tells of how when he was four and very ill in a leading children’s hospital he lived in fear of being forced to eat his dinner and was paraded around the ward being admonished by a formidable ward sister if he failed. We also used to have inflexible visiting hours and the subjection of patients’ comfort to the convenience of medical rounds.

We have enough evidence to say much has changed for the better and nursing has contributed by challenging obsessive rules, routines and hierarchies. I would say this, but I believe this progress is also due to nurses being trained to think, question and innovate through the opportunities of university education and lifelong learning.

Unfortunately, as we know, in today’s fast moving, complex and uncertain NHS, there are systemic and individual failures of care. Yet finger waving at nurses, exhorting them to smile more and the collection of “compassion metrics” may have a perverse effect and lead to defensive behaviour as nurses lose more confidence in themselves and the profession.

Rather than focusing on the individual professional, I think we should learn from the seminal contribution, 40 years ago, of Isabel Menzies Lyth who wrote about nursing practice and the importance of understanding it within the context of the hospital as a social system. Her argument was that organisations can create anxiety and feelings of fragmentation for individuals working within them, which people respond to by establishing protective shells, projecting negative attitudes or what she described as defensive behaviour against anxiety.

The midwife in my postnatal ward was clearly uncomfortable having to come into my room - such a different place from the rest of the ward full of happy mums with bundles of joy. At the time, I felt she lacked compassion, but her behaviour was an understandable consequence of extreme anxiety for which she needed personal support and leadership from the team.

We should shift the direction of the argument in the heated debates about why nursing lacks compassion. It’s often blamed on the wrong sort of students, too much theory in universities, out of date academics and not enough exposure to clinical practice for students. Instead, we should look at how far cultures of healthcare organisations are collegial, patient centred and compassionate and what we can do collectively as universities working in partnership with trusts to make that better.

As Menzies-Lyth would say, it is nurses who are exposed to the stress of the day to day emotions expressed by patients who are at their most vulnerable, and so it is nurses who experience the greatest emotional pressure within the healthcare team.

Nurses must have good quality leadership and support in order to provide individuals with the right care at the right time. It is absolutely right that the Prime Minister’s Commission on the Future of Nursing and Midwifery highlighted the prominent role of the ward sister and charge nurse in creating a culture of support within which organisational compassion can flourish.

Fiona Ross is dean, Faculty of Health and Social Care Sciences, Kingston University and St George’s, University of London


Readers' comments (7)

  • Thank you Fiona for sharing with us-very concise and rational as always

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  • Ms. Ross have you ever read the blog Militant Medical Nurse? If you haven't, then you might want to google it.

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  • Fiona, your article was thought provoking, , please could you give the full reference for Menzies Lyth as I would like to read more. Thanks.

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  • we could do with a great deal more articles in the NT of this calibre to aid us in our thinking and professional practice and which would raise the profile of the journal.

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  • "The NHS National End of Life Care Programme’s report - Talking About End of Life Care: Right Conversations, Right People, Right Time - is based on findings from 12 pilot projects that assessed local training needs and approaches to meeting them."

    I fear that this programme will bring about just the type of stereotyped insensitive communications mentioned above instead of the spontaneity of caring professionals and fellow human beings to fit the individual needs of the patient and the circumstances.

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  • For Yvonne Awenat | 2-Feb-2011 3:21 pm

    Isabel Menzies Lyth (1960)
    Social Systems as a Defense
    Against Anxiety
    An Empirical Study of the Nursing Service of a General Hospital
    A shortened version of the original – Human Relations 13: 95-121

    If you type Isabel Menzies Lyth nurses into the Google search box there is more about her work including articles in Google Scholar. Looks like very interesting and helpful reading. Organisational behaviour was one of my modules for my MSc in healthcare management and my favourite subject it can give so much more insight into team work and the individuals working in the team.

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  • Thank you for this article which gives a really useful example of the outworkings of defensive practice. I am a PhD student applying Menzies' principles to the field of child protection social work, so found your piece fascinating.

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