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Editorial: Follow the yellow brick road- the compassion deficit debate where to from here?

2015; Wiley; Volume: 24; Issue: 19-20 Linguagem: Inglês

10.1111/jocn.12917

1365-2702

Fiona Timmins, Jan de Vries,

Patient Dignity and Privacy

Naïvely, we may have expected the public to rally behind their beloved nurses. Quite the contrary. It was now open season and former patients and families took to the press and internet in droves detailing their own nursing horror stories. (Darbyshire and McKenna 2013p:305). While there seems to be an agreement that ‘compassion failure and compassion deficits’ (Paley 2014:274) need to be addressed by health care broadly, and by nurses specifically, a particular emphasises on teaching compassion to undergraduate nursing students and screening all new entrants for compassionate tendencies seems under intense scrutiny in the arising debate. It is worth pointing out that these latter are a UK phenomenon. Although the profession is likely to be influenced internationally by particular trends, it is not certain that either of these contested developments are widespread. Importantly, if the general consensus is that both screening for and buffering of compassion is required for nursing students, then there are potential consequences for close neighbouring countries like the Republic of Ireland, where little or no a priori screening of nursing students takes place (other than health and criminal background checks) as the application is based on academic merit only. So effectively the rest of the world is looking to see where this debate goes. However, more importantly as Darbyshire et al. (2015, p. 1) point out in a recent editorial there is ‘no clear evidence … that this disturbing pattern is changing’. a constant presence in the clinical environment and as self-proclaimed ‘patient advocates’, nurses must surely be sentinels where failures of humanity are evident. For staff to ignore patients’ pleas to be helped to a toilet and leave them to wallow in a soiled or soaking bed for extended periods because they were ‘too busy’ must surely rank as a ‘sentinel event’. Such events within an ostensibly caring environment demand investigation and subsequent explanation to identify how these occurrences were allowed to happen and what preventative actions will be initiated. The findings of the Francis report and other public health scandals have indeed been well publicised. The report demonstrated the harsh reality of failures in care and compassion towards patients (Francis 2013). In some cases even the most basic care was not provided and patients and their families were let down. ‘Callous indifference’ towards patients was noted (The Mid Staffordshire NHS Foundation Trust 2013, p. 13) with suboptimal communication among nurses and between nurses and other health care workers, resulting in compromised patient safety and care (The Mid Staffordshire NHS Foundation Trust 2013). These findings were compounded by a management culture that prioritised financially driven targets rather than essentials of patient care (Hayter 2013). While some contend that these incidents are not widespread and factors contributing to their occurrence are complex, nurses cannot become blinkered bystanders, powerless victims or worse, wearily resigned perpetrators. As such the benefits of rationalising the staffs’ behaviour (in Mid Staffordshire) is unpalatable for many nurses (Darbyshire 2014, Rolfe & Gardner 2014a,b), although perhaps useful in reducing public fear and restoring public confidence. Thus, the merit of deciding, debating and discerning whether or not there was a wicked witch or whether she was turned wicked by experiences and context (see Wicked™ the Musical) is limited. First, the nursing profession's approach to professional regulation internationally regard personal responsibility very highly. Indeed the serious responsibility held by nurses is highlighted by Darbyshire et al. (2015). Fitness to practice is usually regarded from an individual perspective, and while contextual factors are possibly taken into account, there is no excusing from personal liability. This forms the basis of the International Code of Ethics (ICN 2012) and localised nursing regulations which are suggestive of ethical and moral values that supersede contextual factors and other temptations. The law operates in a similar way, while many contextual factors contribute to deviant behaviour, individuals are held accountable. When an adverse event occurs, it is important to determine how and why the defences failed, not who blundered. (Hinton-Walker et al. 2006 p. 8) how to manage errors more appropriately ….acknowledging that ….errors are not the result of ignorance, malice, laziness, or greed on the part of individuals or organizations. If meaningful … cultural change is to occur, it must be based on the realization that error is a matter of system flaws, not character flaws. (Hinton-Walker et al. 2006, p. 8) So rather than apportioning blame entirely to individuals, organisations perhaps do need to look at organisational structures and solutions. Within this approach understanding negative occurrences, such as occurred in Mid Staffordshire, may be found within the social cognition research; notably the cognitive dissonance and cognitive consistency theory (Festinger 1957, Aronson 2012) which have been little explored or applied in nursing settings. Humans are social animals, and look to each other to determine reality (Aronson 2012). Even when someone knows something to be wrong they can be influenced by their peers who may choose to ignore matters. In some circumstances, there results a gradual process of erosion of personal values within a culture where conflicting values predominate (cost saving or efficiency become more important that compassion for example). Once individuals such as nurses begin to turn off their natural response, which might mean providing less than compassionate care (for example ignoring a patient's call bell), they begin to adjust to this new behaviour by justifying it to themselves (e.g. we are too busy, we are short staffed, she calls the bell too often) this thinking serves to reduce the dissonance (discomfort) that acting contrary to one's own true values causes. Once those justifications become embedded, it is easier to repeat the practice, with less dissonance occurring. This means like the students in the Stanford Prison Experiment (Zimbardo 2007), rational humans can behave in unthinkable ways by following the lead of others and justifying it to themselves over time. Over time people can become very accustomed to the alternative approach and see no wrong in it at all (the dissonance disappears). Because dissonance theory focuses on the mechanisms that motivate humans to maintain consistency between values and behaviours, it might be useful to examine how this takes place in everyday health care situations. Let us assume a nurse is working on a ward and attends to a patient who has just had surgery. The patient is not feeling well, is worried and seems to be in need to share her concerns about this. The nurse indicates that they are under time pressure now, but will return later. As the day unfolds, this does not happen. The nurse goes home and while reflecting on the day realises this omission which leads to feelings of shame. Dissonance between care standards and the care that has been provided is being experienced (see Fig. 1). The reaction is to make a point of redressing this the very next day. Making this resolution immediately reduces the dissonance discomfort and as a result the nurse instantly feels better (dissonance reduction). It is possible that conscious reflection on values may have taken place, but it is also possible that a mostly implicit comparison will have been made between the expectation the nurse has with regard to the quality of care and the actual care provided. An inconsistency has been noted, which will have generated a modicum of discomfort and mild shame. The nurse will have felt motivated to do something about it and having made a plan to do so can abandon further rumination on the issue. In cases such as the example above (see Fig. 1), the ensuing dissonance will be most likely reduced by restoring care levels. This is the most direct solution, bound to reduce dissonance without lingering discomfort. A nurse will likely have been prepared to address problems in care in this way. Providing a strong educational foundation that emphasises professional values and care standards aims to make these core values explicit and accessible in a health care worker's mind while in practice. In addition, training in reflective practice, which most nursing students receive, may facilitate cognitive processes that stimulate thinking and exploration of the extent to which appropriate care standards were achieved. As a result of both, education on professional values and by promoting reflective practice, it is hoped that a nurse will develop the awareness to reflect on emerging differences between actual care provided and optimal standards and values. This would hopefully lead the way to nurses in practice making the necessary responses (as a result of either reflection in or on action). Within this framework, obstacles to providing optimal care that are identified may be addressed and resolved. This is a desirable state of affairs for all involved, and may be aspirational. Certainly there is international expectation that nurses are critical reflective practitioners, and consideration of cognitive dissonance and the role that this may play in health care situations may need consideration within this context. It is possible that the strengthening of values of nurses around compassion might be something that education can provide including perhaps facilitating nursing students to become more aware of cognitive dissonance mechanisms. However, any such initiative needs to go hand in hand with a shift in organisational health care cultures that facilitate and stimulate this. Certainly the findings from the Francis report reveal that it was not merely the delivery of poor care, but the failure to prevent this that compounded the problems (RCN 2013). The Francis Report highlighted that clinical hospital environments need to be such that staffs are able to raise concerns (2013) suggesting that both systems and support structures need to facilitate this. Effective leadership that praises staff's ability to raise concerns rather than penalising them for this is required (Dorrell 2013). Nurses are encouraged to be able to speak out, have their concerns noted, and would likely be more comfortable in an atmosphere were speaking out is accepted and celebrated (Dorrell 2013). However, it is often the fear of reprisals at work that prevent nurses from speaking out (Timmins & McCabe 2005). Those working in education, therefore, while cognisant of the requirements to teach compassion with new vigour also need to consider strengthening elements of communication skills to ensure an assertive, vocal graduate and strong leader. Those working in clinical practice may choose to reflect on local cultures to explore the extent to which they are responsive to addressing issues at a local level before they become major problems. Local support for staff is useful as the experience of cognitive dissonance, if supported early in some way, helps the discomfort to regress, and the nurse is less likely to revert to unintentional blindness. Darbyshire et al. (2015) suggest nurses should be more vigilant and develop a robust system of reporting on ‘dignity emergencies’ and substandard care that could be ‘discussed, adapted and drawn upon to enable us to anticipate, prevent and respond to “these emergencies”’. To do this takes courage. It also takes wisdom. Dewar et al. (2014) also provide an example of how to find out from patients and families what could be done to improve caring experiences. They carried out action research project with patients, families and staff and revealed that engaging in caring conversations can help to place compassionate care at the heart of practice. They suggest the following open questions, which were adopted successfully across their study cites, and which open and engage patients in therapeutic relationships: This same action research study (reported elsewhere) (Adamson 2013) revealed that nurses were more satisfied having provided compassionate care. Being flexible, getting to know the patient and having conversations emerged as key themes in the research. An interesting development in Dewar et al's (2014) action research study was the development of multidisciplinary team (MDT) reflective meetings. These meetings permitted the teasing out of issues in practice that went right or wrong and developed shared learning from this. Celebrating good practice was an important part of this. Central to the success of this approach was the notion that for compassionate care to exist staff needed to feel supported and experience compassion first hand within the organisation (Dewar et al. 2014). This Napier team also provide a range of short tools to help health care staff to develop compassion locally by considering their values and brainstorming issues (Edinburgh Napier University 2012, Edinburgh Napier University 2014). What is required now is some logical thinking (Roberts & Ion 2014) about logical solutions such as reflective multidisciplinary team meetings proposed by Dewar et al. (2014) or matrix for describing dignity emergencies as suggested by Darbyshire et al. (2015). The human is capable of turning a blind eye to matters either intentionally or unintentionally. With this growing awareness, in the UK at least, health care might like to consider encouraging practices that allow open discussion that listen to and address staff concerns, treating them as legitimate and finding solutions that work. As such, building on Darbyshire et al's (2015) suggestions might lend themselves to group reflection mechanisms (Dewar et al. 2014), whereby situations are highlighted early rather than leading to crisis point that requires solutions within the public rather than local domain. …unfortunately some patients have to wait a longer period which at times we cannot help due to high demands on our staff. I am confident that my staff team value each patient as an individual and manage to balance their desire to provide good quality care with the challenge ensuring that the cores tasks of night shift are met… We endeavour to provide patients our optimum care and comfort during a difficult time. Failing to provide fundamental care such as toileting patients … can never be an “unavoidable accident”. However, while agreeing perhaps that curriculum change for nursing students is not the solution; we do believe that the nursing profession may need to consider its own values and examine whether or not these contradict the espoused values of the profession (such as caring, ethical practice and person centred care). In the same way Dewar et al's (2014) participants found that they needed organisational compassion and support, perhaps the nursing profession needs to exude these values both as educators and practitioners. It is possible, that to strengthen compassionate care the philosophy and thrust of nursing faculties, schools and departments could be examined to ascertain the extent to which their ethos is congruent with these values. Rolfe (2012) suggests that many nursing scholars and academics have lost their way in the modern university although the Willis report (2012) found little issues with nurse education overall. However, with increasing emphasis on profit making universities may be placing increasing emphasis on pursing independent funding opportunities with less emphasis on teaching/learning and/or clinical practice (Rolfe 2012). However, this situation is about to change with new increased focus and requirement for retrospective clinical impact of research to be documented and evidenced in the UK Research Assessment Framework Exercise (REF) (McKenna 2012). Darbyshire et al. (2015:1) are correct to challenge the nursing profession to ‘embrace the role of the “human dignity sentinel”’. It is timely now to translate understanding and explanation (of compassionate deficits in care) into action. In keeping with the yellow brick road analogy any such action takes courage, wisdom and commitment. As a component of teaching compassion nursing students could receive education in strengthening of professional values and mechanisms for becoming resilient in the face of social pressures. Reflection and reflective practice in clinical practice will help with this. In relation to the Francis report and other recent health care scandals, articles such as Paley (2013) certainly highlighted the importance of examining problems that occur in health care contexts from a social psychology/systems perspective. However, these notions are also not without their critics (Darbyshire 2014, Rolfe and Gardner 2014a, 2014b, Timmins & DeVries 2014). Certainly a culture which is open, honest and transparent and where integrity, honesty and sensitivity flourish is necessary to offer the required support to staff to be able to deal with dissonance and ensure optimum care standards (Darbyshire et al. 2015). Reflection and reflective practice may be useful mechanisms to support this, perhaps using Darbyshire et al's (2015) suggestion to focus holistically on ‘sentinel events’, which ‘involves watching for, reporting on and learning about incidents’ is a useful adjunct for practice. Seeking regular patient and family feedback on perceptions of care which is discussed and integrated into regular MDT reflective meetings would also be useful. Rather than teaching compassion per se nursing students could be prepared for practice through learning about professional values, ethics, empathy and compassion, and programmes could be enhanced by including practical classes that strengthen values and enhance students’ understanding of the interplay of psychological mechanisms such as cognitive dissonance with professional standards and personal practice. Obviously poor standards of care are indefensible, however, as Darbyshire et al. (2015) point out, we need to move beyond proposed explanations to solutions. As a reflective profession, the message needs to get out that both nurses and academics associated with nursing are actively engaging with and exploring reasons for poor actions/inactions and ways of preventing such occurrences in the future. Nurses need to take their responsibility seriously (Darbyshire et al. 2015); however, it is understood that toxic cultures can develop whereby an ‘institutional heartlessness’ can develop and be spread to others (Wilkinson cited in Chambers & Ryder 2009, p. 2). Mechanisms to prevent this need to be actively explored, researched and imbedded in practice. In our view, an understanding of social psychology mechanisms can contribute positively to any such research and development.