Older Mind Matters

Counting beans: can we measure the things that matter?

Have you read the document “Developing the culture of compassionate care: creating a new vision for nurses, midwives and care-givers” (find it here)?

This new vision contains six fundamental values, the 6Cs of nursing: these are:

  • Care
  • Compassion
  • Commitment
  • Communication
  • Courage
  • Competency

Now I like this model, but colleagues have said to me that the 6Cs are platitudes and wishy washy. Isn't that the problem with healthcare at the moment? All we're interested in are the things we can measure; the things we think are objective; the things that fit with the targets and fashions of our political masters. How do you measure compassion? How do we train people in commitment? Shouldn’t we be able to assume that health care professionals share some basic common values such as the 6Cs? And isn't the attitude that only costs and targets matter part of the care culture that led to the problems culminating in the Francis report? (Find the Francis report here)
I had been wondering whether I should blog about the Francis report but have quailed at the thought. So much has been written and said about it. Much of it we have heard before. Remember the Rowan report?

I went to a talk recently which referenced the Ely report, dating back to 1969. There’s a thought provoking piece in the Ely report:

“Members of the nursing staff who were concerned about conditions must have come to feel that it was almost more than their professional life was worth for them to voice any feelings of concern.”

Do we really think it’s any different now? I have met staff recently from a number of different Trusts, all of whom have said (off the record) that they still feel like that, whatever might be said or written about whistleblowing. The General Medical Council (among other organisations) has guidance on how to raise concerns about patient safety (find it here). It doesn’t compromise, saying:

“All doctors have a duty to act when they believe patients’ safety is at risk, or that patients’ care or dignity is being compromised.”

There is no doubt, however, that whistleblowers don’t do well (see BMJ).

It's curious isn't it - we don't learn, and carry on making the same mistakes repeatedly.The best staff, those who are most committed and care about their patients, are often the ones who feel bullied by the system. I don’t know how we change this, but I do agree with my colleagues in part: a list of 6 Cs isn’t enough to shift the current culture of so-called care. 

Maybe we need to stop tying professionals to pathways and protocols and give them the space to concentrate on bringing their skills to the relationship with the patient.

Or do we need targets to encourage care, compassion and commitment?

5 comments (Add your own)

1. Emyr wrote:
I went to a lecture a few weeks ago, entitled “Supporting the NHS Constitution & the Expression of Care and Compassion”. The speakers were Mike Farrar, Chief Executive, NHS Confederation and Steve Field, Deputy National Medical Director, NHS Commissioning Board. Both were very upbeat and enthusiatic about the NHS Constitution, and its capacity to change all the things Susan identifies as wrong. There were a lot of medical students in the audience, and some of them clealry found it inspiring. Other, however, were sceptical, and I was left with an impending sense of doom: now that these values have achieved the status of a bullet point list, it can't be long before they become part of the target culture.

"Have you done two compssionate things today? Well, then, you've fulfilled your duty to the NHS, and you can go home with your head held high, and your portfolio ticked off for yet another day."

Sun, April 7, 2013 @ 2:43 PM

2. David Jolley wrote:
Measuring up

This is a brilliant blog. I have passed it on to people who I respect as caring, thoughtful colleagues and friends. Several have already responded to me to say thanks for sharing this, and thanks to Susan for writing it.
Maybe one or two of them will write responses to the website, though for some their thoughts are too personal and precious, and may be felt to be dangerous.

The recent residential conference of the Faculty of Old Age Psychiatry at the Midland Hotel included some whiffs of refreshing air. http://www.rcpsych.ac.uk/traininpsychiatry/eventsandcourses/facultysectionconferences/OldAge2013Presentations.aspx
Notable amongst these was the short presentation by Dr Afifa Qazi: ‘Changing practice to reduce admissions in dementia.’
The title proved to be engagingly misleading. One of the outcomes of Dr Qazi’s ‘new’ approach to service development and provision was that fewer people were being admitted to hospital. But what she was doing was wonderfully old fashioned – organising the activities of herself and her team to see patients where they live, work with them and their carers to resolve problems in much the same way that Tom Arie and others taught us 40 years ago (1,2). She had the good sense and belief in her understanding of people’s needs to ignore formulaic management directives, to carry her team with her, and to make things better for everyone as a consequence.

Professor Rowan Harwood, a Geriatrican in our midst despite the absence of any comment about a relationship with Old Age Psychiatry in the recent BGS statement on its current standing, and despite the absence of any attempt to include a BGS/Faculty liaison session in the meeting, spoke to the title: ‘Do shared care wards work?’ He strayed to consider some comments arising from the Francis Reports and other reports on the experiences of older people in receipt of services. Most memorably he drew attention to Professor Marion McMurdo’s rapid response to Sir David Nicholson’s bluster: ‘Alternatives to hospital for older people must be found’. www.bmj.com/content/346/bmj.f453/rr/627444
‘Here is a radical suggestion - make hospitals good places for old people’.

She calmly points to the nub of the problem: our hospitals, urged on by politicians, the media and the general public (in no particular order) hold on to an outdated vision of what problems they might solve for people today when they become very ill.
So we have systems which are designed like factory assembly lines to identify and provide the latest treatments, as quickly as is possible, for single pathologies which happen to be housed in a human frame.
‘Ouch!’ cries the humanity, which inhabits the frame, but finds itself barely consulted about the whys and wherefores, let alone the hows and ifs.

The size and shape of the peg has changed – the size and shape of the receiving hole has to change too if we are to escape from this damaging friction.
Damage there is in all directions and to all parties. Most obvious is the damage to patients, especially those who are old and carrying multiple pathologies which span the physical-mental-social-spiritual spectrum. There is damage too to family and friends who find themselves frustrated, unvalued, and powerless, disenchanted onlookers. And those whose profession is to provide health and social care are damaged, as they find themselves required to work to blueprints to which they have not contributed, with staffing schedules which are inadequate in capacity and skill-mix, and with imposed aims (or targets) which are not theirs, nor those of their patients. When all goes wrong, it is they who are demonized as brutish, ignorant and uncaring.

As Professor Benbow says, this is not a new story. Our lifetimes included recurrent instances of tragedies, insights, resolutions and further failings.

Professors Harwood and McMurdo are right.
My guess is that Sir David Nicholson will be grateful to them and to Dr Qazi and others who stand their ground and speak openly and honestly for what they believe to be correct, put it into practice and learn and teach by revision of services in action. This is not the world of academic ‘evidence-based’ double blind controlled trials. It is the real world of muck and complexity, using everything you know or think you know to produce a fix which fits for now and will be revised when it doesn’t quite fit any longer.

For me, the psychogeriatric movement, which began with taking knowledge and skills out from mental hospitals to make them available in homes and care homes and general hospitals and to learn how they might be best used in these alternative worlds (3, 4), remains a model with hope ingrained.
It began with a poorly resourced, rough and ready but solid base and offered a spectrum across a care-at-home, outpatient, day hospital and inpatient presence. Inpatients included a ration of long-term ‘until death do-us-part’ safe places. The patchwork of individual pioneer services has given way to a country-wide blanket, dyed to a uniformity of pattern and fragmented in some places to the imported and imposed shape of ‘new ways of working’.
So the messages of continuity, individuality and improvisation are at risk of being lost.
The essential of including an expert, accepting, end-of-the-road sanctuary (asylum) within every local system of care is denied and not understood. Thus patients with the most difficult symptoms are at the greatest risk of rejection, to be moved on and on, rather than hugged close and helped through by those professionals who have, or should have, known them best.

Rather than the good news of psychogeriatrics permeating the wider health and social care system, psychogeriatrics (Old Age Psychiatry) risks being broken by the same mistaken and misaligned values, ‘plans’ and targets which have produced the horrors known in many general hospitals and many care homes.

The other innovative movement which has bravely addressed the real needs of people with severe, progressive, life-limiting illnesses during our working lifetime is the revived hospice movement of Cicely Saunders (5). Independent in most parts because of their voluntary funding status, the hospices have established a fine reputation for being thoughtful and caring, for listening to people and working with them to achieve what they want as they approach death. The very recognition and positive acceptance that death will come and exposure to futile additional investigation and ‘treatment’ will achieve nothing useful, is the hospices’ gift of sanity into the insanity of a healthcare system which declares every death a failure.
As Professor McMurdo says, much of the work of our hospitals relates to people who are in the last weeks of very long lives, during which they have done a great deal, but often accumulated a cocktail of pathologies and disability which makes them eventually non-viable.
That’s OK. That’s how things are and working with this understanding by patient, family, health and social care professionals is right in the case of individuals and must be understood by those responsible for commissioning, managing and monitoring the care economy. Somehow the same reality must be taken in by the media and politicians who are influenced by the media and, in turn, feed the media.
Hospices have much to teach the large general hospitals, care homes, community services: the whole system of care and therapy (6).

The combination of the learning and practicalities of (‘old fashioned’) psychogeriatrics and hospice palliative care carries for me real promise that we can remodel our health and social care services so that they radiate care, compassion, commitment, (good and open) communication, courage (to face realities, to think again and accept revisions) and competence (based on humbly learning on the job and not feeling reliant on the findings of the next very expensive ‘evidence-base’ fishing trip before anything is done).

The experiences of psychogeriatrics and hospices and our small adventure in Primary Care at Gnosall (7, 8) all say that engaging competent services with people who are becoming ill, early and in their own environment sets things up for better outcomes.
Continuity from there on (‘Seeing people through’ as Tom Arie put it) can be achieved. It confirms the importance of the individual and makes for better use of all resources.
Members of staff are to be valued for themselves as well as their qualifications and skills. Where people are brought together for care, it is important to staff the resource with sufficient numbers and a spread of skills to provide a safe and fulfilling environment for everyone. People cannot do what is required if they are not given the time, the support and the recognition which equate to the task.

For me the recommendation of a combined Psychogeriatric-Hospice model is that both are already seen to work in smallish ways.
The challenge now is how to interpret their principles into a wider scene

David Jolley April 7th 2013

1) Arie T (1970) Lancet 5 (2) 1179-1182
2) Arie T (1971) BMJ (3) 166-169.
3) Jolley D and Arie T (1978) British Journal of Psychiatry 132 1-11
4) Arie T and Jolley D(1982) Making Services Work: Organisation and Style of Psychogeriatric Services in The Psychiatry of Late Life Edited by R Levy and F Post Blackwell Scientific Publications, Oxford p222-251
5) Brown G (2007) Cicely Saunders; Chapter 7 pp 178-206 in: Courage – Eight Portraits. Bloomsbury Publishing; London
6) Calazani, N., Higginson, I.J. & Gomes, B.(2013) Current and future needs for hospice care: an evidence based report. London: Commission into the future of Hospice care.
7) Greening L, Greaves I, Greaves N and Jolley D (2009) Positive thinking on dementia in primary care: Gnosall Memory Clinic. Community Practitioner 82(5) 20-23
8) Greaves I and Jolley D (2010) National Dementia Strategy: well intentioned, but how well founded and how well directed? British Journal of General Practice 60: 193-198

Sun, April 7, 2013 @ 10:30 PM

3. Michael Clark wrote:
Thank you for writing this Susan. Thanks too for the comments from Emyr and David. A very thoughtful debate on the value of and values in health and social care.

Of course guidelines and checklists and pathways and protocols have a place in health care. At their strongest they codify a great deal of the best knowledge (research and other) in formats that help people to deliver good professional care. (They can help patients and their families too by giving them knowledge of what to expect.)

There is also a place for management techniques like accounting, performance management and related targets. They provide another source of information for thoughtful decision making.

The problem comes when these things become ends in themselves, rather than means to thoughtful, humane action - undertaken hand-in-hand with patients, their families and communities. As the ends, guidelines and the targets then become the reason for organisations and jobs to exist, and 'good professional care' is defined as meeting these, rather than as using good judgement.

In an interesting discussion about Hospital Standardised Mortality Ratios (http://www.lrb.co.uk/v35/n07/paul-taylor/rigging-the-death-rate) we see how the indicator and how it was constructed became the focus of a great deal of debate and energy related to Mid-Staffs - rather than someone at the Trust or the SHA asking, 'is there a problem of care here that we need to attend to?''

Using judgement is not easy and is rarely a matter of a one-off moment in time - which is how some uses of guidelines, protocols and pathways operate. Judgement is ongoing and triangulates many things that have come to bear on a situation, and on how that situation is changing, e.g. research knowledge and guidelines; clinical experience; knowledge of patients, their preferences and social circumstance; legal requirements; ethical dimensions; and a political knowledge of what is expected by those with certain power. If any of these aspects of the environment become too distorting in a situation, in the longer run we lose the art of applying good judgement.

As a process dealing with the complexity of people's lives this judgment can never be stripped down and constrained to simple guidelines, nor ethical codes. Nor, then, should accountability for it be purely about simplistic indicators or tick-boxes - if that happens we have decided the value of care is the indicator, not the humane service to people.

Tue, April 9, 2013 @ 10:47 AM

4. Dudley Ainsworth wrote:
Beans and the Theraputic Miasma

"I use the word nursing for want of a better.It has been limited to signify little more than the administration and the application of poultices. It ought to signify the proper use of fresh air,light,warmth,cleanliness,quiet and the proper selection of diet all at the least expense of vital power to the patient. [nursing the sick little understood].
It has been said and written scores of times that every woman makes a good nurse. I believe, on the contrary,that the very elements of nursing are all but unknown" Nightingale,Florence, 1820-1920.

Is nursing still not sure of what are it's values are after all these years, goodness knows how many attempts have been made to underpin nursing with a model and method of working. The nursing process of the 70's hailed as a way of making nursing understandable and practical,(I will return to the word practical later) and as such the nursing process was heavily influenced and dictated to by the goals of the medical profession.

Many models have been incorporated into nurse training in the 90's Maslow , Roper-et al and Orem to name but a few, others such as Pearson have attempted to represent the reality of and give a picture of what nursing actually is.

What do the 6C's actually mean to nursing? Well they attempt to define what the nature of a caring relationship should be , they are not the sole property of the nursing profession they should be found in any and all care givers, there is an attempt to involve other care givers such as care home owners but really come on lets get real here the care givers mentioned are only the tip of the iceberg, anyone who has worked with communities knows the truth of the matter.

The 6Cs are empathatic qualities which you cannot teach in a tradition way neither can you enforce them upon individuals using the carrot and stick approach. What surprised me most of all was the omission of CLINICAL SUPERVISION and the part it has in the provision of a safe caring and compassionate care giving service.
It is not enough to tell people what to think and how to think but to be enabled to understand why a person thinks that way.It is a shame that such an opportunity has been lost .

Your colleagues are correct Professors Benbow the 6Cs are not measurable in the true sense and appear wishy washy, but has anyone bothered to ask the recipients of care ? if they did they would find that the measurement of the 6Cs is binary and leaves no room for grey areas.I am an expert in this field as I have unfortunately over the last 15 years had to use health services both hospital and community.

That the knowledge which has been accumulated over the years from teams which were formed to meet the need of older people with mental health problems should be looked at as a model which works for patients and their carers. I have had the honor to have been blessed to have been working in such teams in particular the early years of psychogeriatric services. Why did they work so well? They worked because they had strong solid and trusting leadership, the individuals in the team were responsible for their own actions and risk taking but most importantly there was a shared vision and clinical supervision in operation at all times. There were checks and balances within the teams and no one individual was bigger than the whole of the team.
The teams had spent time in developing meaningful relationships with the community in which the patient lived and died.

It is fascinating that if you stop and look at what damage therapeutic nihilism does to care provision, the hospice movement does, as Professor Jolley points out, take a different view, it re-frames the situation, makes sense of the inevitable and creates networks for the patient and carers to feel safe and supported. I makes use of cognitive therapies, some of which may be a bit bhuddist for some people, (mindfulness) above all it treats patients with all of the 6Cs.
Key to any service working is community involvement of general practioners and day care provision. Who knows where the hospice movement would be now if it had not been so constrained by the 1936 Cancer Act!

Returning to the practical nature of nursing, I firmly believe that nursing lost a lot when it changed from an apprenticeship training approach to a taught academic approach and as such perhaps thought needs to given as to how a mixed economy of nurse training and education is aligned to meet the 6Cs.

All is not lost there will always be beans to count but beans come in all shapes and sizes and they all need a different way of being counted.

Tue, April 16, 2013 @ 12:49 PM

5. Victoria Sharman wrote:
Thanks to modern technology and to you Susan in the way you are making use of this resource. Its brilliant encountering great minds at work counting beans and what a variety and healthy beans. The various contributions from the thinkers made me appreciate the value of my focus on later life issues. The beans themselves are tricky and from a cultural perspective, in an on-going case, my 67 year old client described her experience as "climbing a ladder, suddenly two steps down, no top up until you fall and start all over again". This makes me wonder about the nature of 'top ups' and possibilities.

Currently the term recovery focussed services are emerging in different forms and in discussion, a male carer client offered his view as "I think services see themselves as recovery focussed but they still try to fit square pegs into round holes and expect people to fit the model and if they don't they get marginalised

Of the 6Cs, courage made me curious about change e.g. willingness to embrace new ideas, attachment, rituals of care giving .

I am interested in training/practice, supervision and research around developing essentials for work with older adults (individuals, couples and families. I welcome ideas and hope to add to them to my programme of activities tory out including exercises. My email address is victoriasharman04@gmail.com

Thu, April 18, 2013 @ 12:42 PM

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