Over the past few years on the Leicester course we have encouraged trainees to develop their understanding of NHS healthcare cultures by means of a psychodynamic observational task, undertaken in the third year after hand-in of the thesis. The task is a much abbreviated version of the method of Bob Hinshelwood and Wilhelm Skogstaad, which in turn is derived from the approach to infant observation pioneered at the Tavistock Clinic in the sixties. Hinshelwood and Skogstaad invited medical students to conduct weekly observations over a three-month period within a healthcare setting of their choice, paying detailed attention to what was going on externally, to the atmosphere and interactions between people, but also taking careful note of their own feelings and reactions to what they observed. The students then brought the observational material to weekly supervision groups, in which discussion was focussed on working together to process and find meaning in it.
The original aim in developing this task in the context of clinical psychology training was to help trainees see the environments in which they work through fresh eyes, and to learn about the unconscious dynamics that can underpin some of the more puzzling ways in which healthcare staff relate to patients and to each other. But the project has been given new meaning by the seemingly endless train of recent reports on the apparently uncaring and cavalier attitude of staff on NHS wards. Most notably there was the Francis report last year, which directed public and media concern on the question of how to create and maintain a culture of care, rather than one which is driven by financial considerations and anxiety about professional survival.
The emphasis of much of the debate post-Francis has been on how to improve systems to prevent things going wrong again. It is surely a good idea to think about how to make systems better, but it becomes a problem when attention is focussed exclusively on the managerial or behavioural aspects of system improvement at the expense of emotional and interpersonal issues, particularly in the so-called human services. Media reports and conference agendas that have appeared on the subject can imply that if only staff were recruited and trained properly, and were managed and overseen effectively, mistakes of the kind that occurred in Mid-Staffs would not happen again. The difficulty is seen as one of incompetence: people just need to do their job better, as simple as that.
But as many of my NHS colleagues and I see it, things are more complicated than that. Our experience is that well-trained and well-meaning staff can find themselves involved in chaotic and uncaring practices, and indeed can imagine making serious mistakes, if the emotional challenge and complexity of the work they do goes unrecognised and unsupported by the organisation. Many of my NHS colleagues have responded to what happened in Mid-Staffs with the old saying ‘There but for the grace of God go we’.
The job involves relationships with people in difficulty and distress, and it should go without saying that this has an emotional impact on staff. If this is not acknowledged and staff are not given space to process and make sense of the feelings they have in response to the work they do, services evolve in defensive ways that all too often interfere with the provision of high quality patient care, and sometimes serve to actively undermine it. Isabel Menzies Lyth gave wonderful examples of this in her classic late 1950s study of the nursing service in a general hospital, which our trainees read in their second year, often commenting upon its resonance with their experience of the modern NHS. One of her many observations was that staff unwittingly dehumanised patients, referring to them as ‘the liver in bed 20’ and organising the service so that nurses had tasks to do across patients rather than people to care for. This served the function of protecting them from the emotional impact and what felt like the overwhelming responsibility of caring for people with serious illnesses. Staff did not want or intend to develop an uncaring service towards patients, indeed quite the opposite. But some inhuman practices did evolve in the absence of acknowledgement at an organisational level that caring for people who are seriously ill and may get more unwell or die is an emotionally difficult job that staff need help with, and that serious thought should go into how best to do this.
Things have changed since Menzies Lyth’s time. In particular over the past few years we have faced unprecedented cuts to public services, and NHS mental health services have been badly effected. Many of our senior clinical psychology colleagues, the repository of wisdom, calm and experience, have taken early retirement or had their posts cut, and I suspect that we will be feeling the destabilising influence of this for many years to come. Menzies Lyth focussed her observations of defensive practice on the way in which patients project anxieties into staff, and on how staff were effected by their contact with sick and dying patients. But in the current climate morale amongst staff is extremely low, and clinicians often feel threatened by managers whose agenda is often a primarily financial and short-term one, and who are presumably anxious about their own professional survival, such that their availability to patients can be seriously compromised. Indeed, in one of the more detailed ward observations undertaken by a Leicester trainee, a persecutory relationship between staff and managers was the primary feature of the dynamics of the work setting, certainly in terms of the emotional preoccupations of staff.
We hope for change in 2015, and to be part of that change, and in particular for recognition of the challenge, complexity and importance of the work of care in the NHS.
Arabella Kurtz, December 2014