The quality of care that older people receive is the subject of several recent reports but how can a sustainable change in culture be created to improve care?
The Delivering Dignity report by the Commission on Dignity in Care for Older People provides direction on how to improve care for older people, but a better understanding is needed of how to develop sustainable cultural change.
Citation: Onyett S (2012) Creating a culture to deliver compassionate care. Nursing Times [online]; 108: 14/15, 12-13.
Author: Steve Onyett is visiting professor at the Universities of the West of England and Central Lancashire and director of Onyett Entero.
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The latest report from the Commission on Dignity in Care for Older People (2012), Delivering Dignity, provided excellent direction and should be acted on urgently. The Care Quality Commission (2011) described failures in caring for older people as a problem of organisational culture arising from poor leadership and staff attitude but Delivering Dignity again failed to get to grips with why culture change is so difficult to achieve. Why do we find ourselves here again, what can we do differently to bring about change? Six inter-related issues are highlighted below.
Interacting with care
Delivering Dignity represents an advance in terms of its attention to the detail of interactions between staff and the individuals they care for. Culture change is “radical” change in the sense of being deep-rooted - rooted in the patterns of interactions that constitute the lived experience of life on wards or in care homes. For example, if it is an unfamiliar experience for a patient to be referred to by their first name by someone from outside their family, they may find it disorientating and devaluing. It might be the first step of a process of failing to see the whole person that culminates in them being asked to urinate into a pad in their bed rather than being helped to get to the toilet.
Suchman et al (2011) described organisations as conversations, wherein: “We are creating the organisation anew in each moment by what we are saying about it and how we are relating to each other as we carry out its work.” As the report stated:
“The way staff interact with an older person has a profound effect on that person’s life” (CDCOP, 2012).
The report advocated recruiting staff on the basis of the compassion they display (CDCOP, 2012). This is laudable - but a challenge. Seminal nursing research such as Menzies (1967) highlighted that it is not so much about recruiting for compassion but more about helping nurses stay compassionate.
More recently Handy (1990) described how many new nurses were troubled by discrepancies between daily routines and positive practice values. This led to failed attempts to develop more therapeutically oriented relationships with patients. These failures trigger defensive reactions, with one solution being to adopt a more routine-oriented attitude towards work. As a result, the compassion that new staff have when they arrive gets diverted into a defensive reaction. This then creates the conditions where the values that brought them into nursing in the first place are undermined.
So how do we stay compassionate? Delivering Dignity was right to highlight the simple imperative to defend time to reflect on care provided and how it may improve. However, leadership, support and supervision also need to be explicitly ethical and values based.
The “Golden Rule”
There is much talk of “transformational” leadership. I have always found this word problematic because it carries the implication of sweeping away everything that currently works, which is the wrong place to start a sustainable approach to improvement. In fact the original use of “transformational” referred to that which turns followers into leaders and leaders into moral agents (Burns, 1978); in other words it is about releasing leadership capacity to act on the basis of the highest values.
The report stated: “It is individual decisions to do the right thing that ultimately change an organisation’s culture” (CDCOP, 2012) . This needs to be seen as more important than just “doing things right” in procedural terms.
Perhaps the only rule we need is the “Golden” one. Karen Armstrong, who launched the Charter for Compassion in 2009, highlighted how the “Golden Rule” of doing to others only that which you would have done to yourself has emerged independently in a variety of spiritual traditions (Armstrong, 2009). She stressed that, for this principle to make a difference, it should be applied in every moment of every day.
If leaders are to influence attitudes they need to get the transactions concerning whom they employ right. But, beyond that, transformation involves creating a more positive emotional climate through modelling compassionate ways of being, in relation to others, and particularly users of the service. It also involves engaging staff by showing authentic personal concern for them as individuals.
This is not just about being nice. There is hard evidence that creating positive emotional climates and showing authentic personal concern for staff is engaging and leads to better outcomes for both staff and patients (Alimo-Metcalfe et al, 2008) .
The sovereign purpose
Ganz (2010) defined leadership as “taking responsibility for enabling others to achieve shared purpose in the face of uncertainty”. Once again, the evidence shows that being clear and strong on purpose is key to effective service design (Seddon, 2008). This should be the focus of the “learning through doing” described in the report (CDCOP, 2012). To achieve this understanding, those who design systems of care and those with authority need to look in detail at how their service caters for people who use it.
Achieving purpose also means we are not coy about the exercise of power. This needs to be intertwined with how we show love and compassion. Martin Luther King (1967) was clear about the fact that power and love need to come together to serve purpose. For nurses, exercising power means being fully aware of all sources of their authority including, as academically trained practitioners, people with relevant life experience and compassionate human beings. Effective human systems align these sources of power rather than compromising them.
Importantly, the meaning and social value of work for staff is promoted where work is organised in such a way that it allows them to see how their contribution fulfils a valued purpose (Parker and Bevan, 2011). Staff talk of tasks being “beneath them” when they lose sight of the importance of their work both to the person concerned and wider society.
Staff are further devalued by poor conditions and a culture that suggests they are “feckless and dim” and, therefore, need to be kept on track with targets and close monitoring. Instead, as Bennis and Nanus (1985) stated:
“Great leaders often inspire their followers to high levels of achievement by showing them their work contributes to worthwhile ends.”
We need to consciously avoid a cynical rhetoric of failure that merely drains energy and commitment, and contributes to a diffuse loss of meaning for staff.
The leader as host
Effective leadership is about creating space for people to shine, not stifling them with monitoring, rules and procedures. The recent Good Work Commission highlighted that staff stay motivated when they can operate with appropriate autonomy, develop competence and feel personally supported and connected (Parker and Bevan, 2011).
We need to rethink leadership so it is understood to be about unleashing the capacity of everyone to work at their best at all levels of the organisation. McKergow (2009) revived the ancient notion of leaders as hosts who create spaces where people can find or reclaim meaning and purpose, and give the best of themselves.
The coproduction mindset
My only criticism of the CDCOP (2012) report is its title, Delivering Dignity, which undermines some of its key messages about the importance of seeing older people, their families, friends and carers as partners in care rather than a nuisance or interference. The report helpfully advocated the everyday involvement of family, friends, carers and volunteers in line with clients’ wishes, and suggested that care homes be seen increasingly as part of the wider community.
The report also highlighted the importance of every environment offering a sense of security, belonging, continuity, purpose, achievement and significance. Retaining a sense of purpose means “having valued goals to aim for, the sort of things that make it worthwhile getting out of bed in the morning, and provides a feeling of ‘I have a contribution to make’” (CDCOP, 2012). Making such a contribution promotes wellbeing and requires a new mindset - a shift from care “delivery” to the coproduction of care through relationship. It is only with such shifts in mindsets that we can hope for a future with sustainable spaces where together we can build warmth, compassion, meaning and connection.
- The way staff interact with older people is of key importance
- Ensuring nurses stay compassionate is a major challenge
- Staff need to be encouraged to “do the right thing” as well as “doing things right”
- Leaders should show staff the purpose and meaning in their work and act as “hosts”
- Staff need to develop a new mindset and move from care “delivery” to the coproduction of care through relationships
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